1. Department of Human Services Self-management Improving care Caroline Frankland Senior Project Officer Health Independence Programs Department of Human Services 5 December 2006

2. Self-management Considers the individual, their family and the health professional Holistic approach acknowledging the medical and psycho-social components Empowers the individual through proactive and adaptive strategies

3. Individual’s perspective Know their condition Negotiate a plan of care Engage in activities Monitor and manage symptoms Manage the impact

4. National Chronic Disease Strategy National approach to chronic disease prevention and management Endorsed in 2005 at the Australian Health Ministers’ Conference High level guide to inform policy development over the next 5-10 years

5. National Chronic Disease Strategy Comprises three complementary components –National Chronic Disease Strategy –National Service Improvement Frameworks –Blueprint for Nation-wide surveillance of chronic diseases and associated determinants Implementation is to be developed based on local needs as these are identified

6. National Chronic Disease Strategy Common themes include: –Emphasis on health promotion, prevention and monitoring –Supporting integrated service provision and multidisciplinary care –Promoting and supporting self-management within the health system –Progressing mechanisms for improved quality of care –Improving access

7. National Chronic Disease Strategy NCDS consists of 7 key principles Principle 3: ‘Achieve person centred care and optimise self- management’ Four key action areas identified reflecting overall theme of chronic disease prevention and care across the continuum Action area 4: Self-management

8. National Chronic Disease Strategy – Action area self-management Six key directions: –Identify opportunities to promote self-management –Support training to develop skills to support self- management –Consider self-management as part of care plan development –Promotion of involvement & research into the barriers to such involvement –Improve capacity of broader sector support for self-management –Tailor self-management to meet needs

9. Victorian Policy Environment Public Health branch previously funded 4 research projects Final research paper entitled ‘CDSM Where should Victoria go’ provided 3 key recommendations: –Need for overarching CDM strategy –Integration of self-management across acute & primary care –Need to promote broadly the concept of self- management

10. Victorian Policy Environment DHS internal working group established to examine work being undertaken around self-management Representation from –Public Health branch –Primary Health branch –Programs branch Development of a discussion paper

11. Other DHS Activities Primary Health Branch –Integrated Chronic Disease Management –Early Intervention in Chronic Disease (18 sites funded) –PCP Mapping of Self-Management programs / interventions

12. Programs Branch Care in Your Community Policy Client-Centered Care ‘Treatment and care provided placing the client at the centre of their care and considers the needs of carers’.

13. HARP-CDM and Self- Management Usual Care GP care Self-management programs Access to mainstream community services Generic telephone advice Primary Prevention For example: Obesity reduction / smoking cessation Level 4 Whole population Level 3 People with chronic diseases and/or complex needs Level 2 People with chronic diseases and complex needs who use hospital or are at risk of hospitalisation and are assessed as meeting the HARP-CDM Screen Level 1 People with chronic diseases and complex needs who frequently use hospitals and are assessed as meeting the HARP-CDM Screen Intensive Care Coordination Care across the continuum Tertiary and secondary prevention Enrolled patient population Comprehensive assessment and care planning Specialist medical and GP management 24 hour advice Additional services where appropriate Self-management approach Comprehensive hospital discharge planning Early Intervention in Chronic Disease HARP- CDM Public Health Intensity