Integrated Chronic Disease Care (ICDC)
New care coordination and allied health services for chronic disease care in the South West
Through the provision of care coordination in a primary care setting and access to a suite of allied health services,the new Integrated Chronic Disease Care program delivered by GP down south, will improve integration and coordination of services in the South West for people living with chronic conditions.
The service is primarily for socioeconomically disadvantaged populations living in the regions of Augusta, Margaret River, Nannup, Bridgetown, Boyup Brook, Manjimup, Pemberton, Collie and Harvey.
One of the long term outcomes of the new program is a reduction inpotentially preventable hospitalisations associated with chronic disease and multiple morbidities. The conditions targeted by the program are some of the leading causes of chronic potentially preventable hospitalisation in the South West and were identified as regional priorities through a South West needs assessment and local consultation undertaken by WAPHA and WACHS.
Integrated Chronic Disease Care program will focus on diabetes, cardiology, respiratory and musculoskeletal chronic conditions.
Primary health care is central to the new Integrated Chronic Disease Care program and GP down south will work with GPs and practice nurses in the South West to support the deliveryof the program.
Care Coordination, in the primary health care setting, is a key element to the program. Care Coordinators will support clients to receive the most appropriate care to meet their complex and chronic needs. Multidisciplinary allied health teams funded under the new program will be determined in conjunction with local needs and further consultation with regional health planners.
The Integrated Chronic Disease Care program will support increased efficiency and effectiveness of existing and new services, including digital health and group programs supporting preventative care and optimal self-management.
The programwill also work in collaboration with allied health providers, specialists, Down South Aboriginal Health, South West mental health providers as well as Asthma WA and Diabetes WA telehealth services to improve integrated and coordinated care pathways and communication with patients.
Clients of the Integrated Chronic Disease Care program will benefit from person-centred coordination and management of their chronic and complex conditions in the primary health setting.
This program is funded by WA Primary Health Alliance and supported by the Australian Government under the Primary Health Networks program for the period 1.7.2017 to 30.6.2018.
For further information and discussion, please contact:
ICDC Program Coordinator in the GP down southBusselton office, ph9754 3662 orChief Executive Officer, Amanda Poller, .
Date: 19.06.17