Operationalisation of self-management across Australia
Chronic Disease Self Management in Primary Health Care: evidence and practice

Professor Mark Harris
Centre for Primary Health Care and Equity
University of New South Wales.

Evidence
We recently conducted a systematic review of the evidence relating to chronic disease
management in primary care. From this it is clear that CDSM is one of the most effective
strategies in improving health outcomes for patients with chronic conditions such as arthritis,
asthma, diabetes. It effectiveness is enhanced when combined with other strategies such as
developing patient care teams.

Implementation
Our qualitative evaluation of one of the Sharing Health initiatives was conducted 12 months after its
completion in SW Sydney. From this it was evident that health care workers involved in the
initiative were very satisfied with the program and its fit with their work values. However its
sustainability was adversely affected by lack of flexibility of the program, its translation into other
languages and its engagement with general practice. However the most important adverse factors
were other work pressures on the providers involved. The Area faces acute workforce pressures
and also demands the primary care nurses to focus more attention on post acute care. This has
made it difficult for staff to continue to find the time and other resources to conduct group education
sessions.

Conclusion
We believe that CDSM is an effective strategy which needs to be better integrated into other
primary care initiatives (assessment, care planning, ongoing management & follow up), and that
education needs to be led by peer educators as well as health care workers.

- - - - - - -

Developing the capacity of the primary healthcare sector to respond to chronic disease Victorian initiatives

Dr Jennifer King, Director, Programs Branch
Metropolitan Health and Aged Care Services
Department of Human Services, Victoria.

The need to ensure that the service system is responsive to clients with chronic disease has been identified as a key policy direction across the Department of Human Services. Significant investment has been made in planning and redesigning the service system to facilitate the provision of client centred care across the care continuum.

The Department of Human Services has a range of initiatives and programs to enhance system capacity to support people with chronic and complex conditions:

Victoria’s Primary Care Partnerships (PCP) model is a platform for the primary care providers to engage in local area healthcare planning and provide input into organisation of the service system to enhance
coordination of services across the care continuum.

Hospital Admission Risk Program – Chronic Disease Management (HARP-CDM) and Early Intervention
in Chronic Disease (EIiCD) are established programs to respond to chronic disease demand and enhance
self management in the ambulatory setting.

Care in Your Community area based planning trials are the next step in addressing the needs of
communities and the learnings from PCPs, HARP-CDM and EiiCD. A new planning framework is being
developed and 3 specific pilot projects are underway to develop new chronic disease management service models and address self management more broadly.

- - - - - - -

System changes to increase Self Management support in South Australia

Bruce Whitby, Manager
Primary Health Care & Chronic Disease Strategies
Department of Health, South Australia.

This presentation will focus on system level changes to out-of-hospital services in South Australia, including reform programs such as GP Plus Strategies, chronic care programs and the Australian Better Health Initiative to provide the networks, venues and activity bases for new self management programs.

Integral to the above initiatives is a Statewide approach within SA Health to the training (Flinders Chronic Disease Self Management model and Stanford Lorig model, including use of a State Stanford model license), accreditation of quality and safety standards, and service delivery models to accommodate the diversity of health regions in SA. Program planning is incorporating a broad ‘across the spectrum of health’ view, using population health planning approaches to ensure that programs are targeted to low SES and Indigenous populations. Programs will link in with other health reform initiatives such as the ABHI School and Community Program; ABHI Risk Factor Programs; Chronic Disease Community Programs; GP Plus Centres and Networks; Clinical Networks; and the National Health Call Centre Network.

The Statewide approach to the implementation of self management programs in SA will broadly align with the Wagner chronic care model - a collaborative multidisciplinary team approach; decision support tools including online access to clinical guidelines; reminders and checklists; integrated services; self
management tools; communication links; and care co-ordination through care planning. SA is developing a process on the “how to” of implementing evaluated programs such as Lorig/Stanford and the Flinders model as part of core business and how training and education is being used to develop capacity and support changes to the primary health care sector.

- - - - - - -

Self-management policy initiatives in Queensland

Professor Andrew Wilson, Executive Director
Policy, Planning and Resourcing Division,
Queensland Health

Promoting and improving self-management capacity is accepted as a key component of chronic disease management. While it is easy to understand what this means at an individual level, when planning a state-wide program in the Australian health system it is less clear what this means and how this can be achieved in a coordinated strategic way.

The Queensland Strategy for Chronic Disease has been underway for 2 years. The Strategy focuses on both the enablers of better chronic disease management and developing and improving specific services in collaboration with partners. A remaining piece of the jigsaw is the development of a coordinated systematic approach to promoting self-management across different disease interest and professional groups. A draft framework has been developed and this paper will discuss along with some of the issues in implementing it.

- - - - - - -

Self-management policy initiatives in Western Australia

Ms Karina Moore, Senior Development Officer
Health Policy & Clinical Reform, Department of Health
Western Australia.

Key Theme: Current Policy and Program Initiatives in WA

The Commonwealth Department of Health and Ageing has had a long involvement in Chronic Disease Self-management (CDSM) through the Sharing Health Care Initiative (SHCI). WA through the Canning Division of General Practice has been involved with the SHCI since the programs inception in 2000. To continue to build on this initiative, WA Health, within the Australian Better Health Initiative and through the Ambulatory Care Strategy, will partner with key stakeholders to deliver a state-wide, comprehensive approach to chronic disease self-management.

WA Health has commenced planning, with these and other key stakeholders, toward incorporating CDSM into the health care landscape in WA. It is anticipated this strategy will be operational by July 2007.

The West Australian strategy will comprise of five essential elements: culture; awareness;
knowledge and skills; services; and products. These will be operationalised through four key
tasks: provision of resources and direction; selection and development of a suite of selfmanagement
programs (products); creation of referral pathways ensuring access and, in
collaboration with the Australian Government building the professional capacity of health care
providers, specifically primary care, nursing and allied health. The elements and tasks will be
embedded in a robust evaluation framework that links research and practice and effectively
evaluates patient outcomes and health care costs.

Partnership and collaboration will underpin the delivery of CDSM in Western Australia by
increasing access to programs for both patients and health professionals.