Managing and Enhancing Care Co-ordination in Chronic Disease Management

Speaker: Jan Ironside

June 20 2014

On Friday 20 June, HCCA in collaboration with the Chronic Care Program at the Canberra Hospital hosted a health issues group on how to better manage your chronic conditions and what services the Chronic Care Program provide to the community in order to achieve this.

The growing ageing population has led to an increase in the number of people developing and living with chronic conditions. This has brought up global concerns as there are limited resources to accommodate for the increase in patients. In response to this growing health issue, the Clinical Care Program has trialled a successful project that focuses on better self-management and person centred care.

The project works to maintain patient safety, ensuring that people are informed decision makers and more in control of their health. The Chronic Care Program categorises people using their level of need; category 1 for high needs and category 2 for low needs. This enables staff to prioritise and appoint the appropriate amount of time to each of their patients, improving efficiency but not decreasing the quality of care received.

All people referred to the program by nurses or general practitioners are contacted immediately by an assigned care co-ordinator and are categorised as category 1. The care co-ordinator assesses the living environment of the person through a home visit and helps them to create a care plan that is specific to their needs. They can also make any appointments the person may need and can accompany them for extra support. Phone calls are made regularly to the person to ensure they are on track with their plan and self-managing their condition.

Once the person has become familiar with their care plan and have gotten into a regular routine, the person graduates from category 1 to category 2. Category 2 allows people to have more independence with managing their condition. Phone calls become less regular and the care co-ordinator slowly becomes less involved in their care routine.  Once the person feels in control of managing their condition without much assistance from their care co-ordinator, either the co-ordinator or the person can recommend to be taken off the program.  

Alongside this project, the Chronic Care Program have collaborated with the CSIRO in a nationwide trial of the Tele-health home monitoring devices that further educates and supports people with chronic conditions to manage their health and improve their quality of life. The devices allow people to self-monitor and measure their blood pressure, blood sugars, lung capacity, body weight and temperature and perform a basic Electrocardiogram (ECG). This information can then be transmitted securely through a high-speed internet connection (provided by the CSIRO) to health professionals who can assist the person with any concerns they may have via a telephone call. This helps to reduce the number of unnecessary hospital and doctor visits and the costs that are associated.

With the success of their trial, the Chronic Care Team hope to increase their capacity to expand this promising program. For more information, contact the Chronic Care Program on 02 6244 2222.

By Khalia Lee

HCCA Administration Assistant