Integrated Care for People with Chronic Conditions

Introduction

Following the evaluation of the Chronic Disease Management Program (CDMP), a redesign process has been undertaken to align the CDMP with the Integrated Care program.  Once fully implemented, it is intended that there will be a statewide model for local delivery of integrated care to patients with chronic conditions. The model will have some consistent elements to support equitable access and enable comprehensive evaluation, while also providing local flexibility to ensure that the needs of individual patients can be met.

To reflect the alignment of chronic disease management within the NSW Integrated Care program, and the related reform occurring at Commonwealth level, the redesigned model will focus on the delivery of ‘Integrated Care for People with Chronic Conditions’ (ICPCC).

The ICPCC model strengthens the emphasis on:

• selecting the right people and matching them to the right intervention;
• the importance of engaging patients and carers and collecting Patient Reported Measures;
• the need for collaborative relationships with Primary Health Networks and General Practitioners, and supporting capacity and capability building in primary care; and
• the need for technology to support shared care planning, information sharing and data collection.

Aims and objectives

Similar to the NSW Integrated Care Strategy, the aims of the Integrated Care for People with Chronic Conditions model are to improve health outcomes for people with chronic conditions, including:

• more patients who can be cared for in the community receiving their care there, with a reduction in avoidable hospitalisations, frequency of hospital admissions and Eemergency department attendance, and length of stay in hospital
• providing greater access to out-of-hospital community-based care
• improvements in patient reported health outcome and experience measures.

The target cohort for ICPCC is people with one or more chronic conditions who are:

1. at risk of hospitalisation in the next 15 months; and
2. likely to benefit from one or more of the Integrated Care Intervention(s).
   
   

© – Copyright – New South Wales Ministry of Health for and on behalf of the Crown in right of the State of New South Wales (NSW MOH website viewed on 14 February 2017)