Integrated care for patients with chronic conditions

Following the evaluation of the Chronic Disease Management Program in 2015 a redesign process has been undertaken to align the Chronic Disease Management Program with the NSW Integrated Care Strategy. The new model, Integrated Care for Patients with Chronic Conditions reflects Commonwealth reforms and support equitable access, comprehensive evaluation and local flexibility to ensure the needs of individual patients can be met.

The Integrated Care for Patients with Chronic Conditions model strengthens and emphasises:

• 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 care networks and general practitioners, and supporting capacity and capability building in primary care
• the need for technology to support shared care planning, information sharing and data collection.

The model has been introduced to health services in stages over the past 12-18 months and will continue to adapt and be refined as new shared learning is developed overtime. This model aligns with the health care reforms underway in primary care, and the implementation of Commonwealths Health Care Homes model, supported by the recommendations in the Primary Health Care Advisory Group Report: Better Outcomes for People with Chronic and Complex Health Conditions

Identification and selection for integrated care for patients with chronic conditions

Integrated Care for Patients with Chronic Conditions:

• focusses on the identification of people with one or more chronic conditions who are at risk of rehospitalisation in the next 15 months
• focusses on those who are more likely to benefit from one or more of the integrated care interventions
• is supported by an evidenced based clinical risk assessment tool for selecting patients to the right support intervention.

Integrated care interven​tions

The information collected in the patient identification and selection steps will help to inform the next steps for intervention support. The appropriate intervention is based on clinical judgment and patient goals, and is always in partnership with the patient. NSW has defined three integrated care interventions:

Health coaching

A patient-centred approach to goal-setting, active learning and self-management that guides, empowers and motivates an individual to change their behaviour. Health coaching programs support patients to modify their own behaviour, self-manage and monitor their chronic conditions and medications.

Care navigation

The role for care navigation is to facilitate access to services for the care of a patient, their carers and family for a defined episode of care. The aim of care navigation is to:

• improve the timeliness and appropriateness of care
• reduce barriers to access to care
• reduce failure to follow up
• support patients to navigate the health system
• reducing unplanned admission to hospital.

Care coordination

Deliberate person-centred organisation of patient care activities between providers to facilitate self-management, appropriate care, health outcomes and greater efficiency. Patients enrolled into the integrated care program are monitored and supported for the duration of the intervention. A key aim is to empower patients to self-manage, understand their illness, and seek additional support and intervention when required.​​