Partnerships in Chronic Disease Management

Building on the closer relationship between the Local Health District and the Primary Health Network, patients can with chronic and complex needs can expect better co-ordination of care between the primary and hospital sectors. The Health Care Home model of patient management, long promoted on the North Coast, will provide better care. This will be welcomed by both patients and clinicians alike. Kerry Wilcox, Cardiac Services and Chronic Disease Program Manager for the Northern NSW Local Health District, outlines the new arrangements. 

Chronic disease management (CDM) services in the Northern NSW Local Health District (NNSWLHD) have been undergoing changes recently. The new focus is on working more closely with our partners to provide "the right care, at the right place, in the right time" for patients under the Health Care Home model of care. For GPs the CDM team will contribute to the seamless patient care that extends from the patient's home all the way into the hospital.

Eligibility

To qualify under the new model patients must:

1. be adults (over 16) who do not live in a Residential Aged Care Facility (RACF) and
2. not have a current case manager (other than for mental health) and
3. have needs that would benefit from short term assistance and 
4. have one or more chronic diseases / complex care needs
   1. with high carer stress or
   2. a recent escalation of their condition or
   3. recent hospitalisation

There is a chronic disease manager and a mental health contact person allocated to for each general practice to answer any questions GPs may have. To make contact with your local manager ring 1300 361 465 (see below). (Note: If required the CDM program can consult with Mental Health case managers to advise suitable linkages to community based services.)

Services

For all referred patients

Care Navigation and Safe Clinical Handover

Timely and accurate information exchange between services is essential for improving patient outcomes. The CDM staff will:-

• Liaise with the patients and their carers, discharge planners and GP to identify needs when in hospital.
• Provide ‘my home plan’ for patients so they know who will be providing care for them on discharge and can contact the services when needed.
• Contact the patient by phone within 48 hours of discharge to discuss additional concerns.
• Provide a home assessment within a week of discharge (for new patients) having discussed with the patient's usual GP any issues that may not have become apparent during the hospital admission.
• Report back to the GP ongoing management issues and negotiate ongoing care co-ordination if needed.

(Note: GPs can claim the MBS case conferencing item numbers for these discussions. Conferencing can be face to face, or by phone or video link. The patient does not necessarily have to be in attendance.)

Additional options for selected patients:

Care co-ordination

The care co-ordinators can assist GPs and practice nurses link patients to appropriate LHD, Non-Government Organisations (NGO) and other service providers in the community as part of the patient's individual care plan.

Case management

By liaising with the health care home team, care co-ordinators can provide short-term case management. Chronic and complex patients are then able to:-

• Access the services they need in the community. 
• Navigate the health system.
• Get assistance for strategies to improve their self-management.
• Contribute to their shared care plan (GPMP).
• Contact the CDM team to arrange a case conference or care plan where required.
• Arrange for ongoing long term support as needed.

Health Coaching

There is also the option for the CDM team to provide individualised health coaching to patients who require additional assistance in addressing chronic disease risk factors, better self-management and monitoring of their progress. 

How do I refer?

Please address referrals to Chronic Disease Management at your local Community Health and include all relevant information such as the reason for referral, a health assessment, care plan and the type of service/assistance required. To make contact with your CDM team phone 1300 361 465.