1. Integrated Chronic Disease Management The Victorian Context Ruth Azzopardi, Department of Health

2. Why the continued focus?? Clients say: Care plans are important They want 'a point of contact‘ Transitions within and between organisations) are not be well managed

4. Victorian Health Priorities 2012 - 2022 Issues:  uncoordinated and fragmented system  difficult to navigate for patients and practitioners  increasing levels of chronic disease, aging population, evolving technology and rising cost of services  system facing considerable challenges and will struggle to meet future needs

5. Victorian Health Priorities 2012 - 2022 Priorities:  Improve every Victorian’s health status and experience  Expand service, workforce, and system capacity Expand capacity in community settings and homes, in relation to primary medical care, early intervention and disease prevention, and chronic and complex disease management Build an interdisciplinary workforce to improve care coordination

6. Directions Prioritising services to high needs clients Early intervention Person centred care Support that assists people to better understand and manage their own health (self management, health literacy) Partnership to improve the coordination of care for people with chronic and complex needs Mixed models of care that include service funded through, private, public and MBS

7. Person Centred Care Consumers: having an active role in their own health managing their ill health being a key part of the health care team informing the development of the health care service system

8. The cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health

9. Goal oriented care planning

10. Coordinated care Who’s in charge

13. Delivery system design Decision support tools Self management support Clinical information systems Community Access & Initial contact INI Assessment Care planning Care delivery Monitoring & Review Transition & Exit Proactive recall Health System Coordinated Easy to navigate Accessible Intervention as early as possible Person Centred A Framework to Get There

14. Agency Inter- agency care planning Use of SCTT E-referralSelf management support CQIClinical care protocols MCHS Melb Health INW PCP Initiatives that address key improvements

15. Inter agency care planning (delivery system design) Doutta Galla CHS – Care planning tool developed by EIiCD Working Group to support interagency process and protocol Use of SCTT referral (clinical systems information) North Richmond CHS - Appointing an INI worker, modelling role & pathways E-referral (clinical information systems) Info exchange s2s used for NYCH – City of Yarra referrals Consent documentation (decision support) Melbourne Health - Audit of Medical Records Files July 2011

16. Self management support provided to consumers and documented (self management support) North West Area Mental Health (in partnership with Moreland Hall) – Motivational interviewing rolled out through Advanced Clinician Training – Dual Diagnosis Quality improvement processes for ICDM (health care organisation) SVHM organisation wide formalised QI processes with annual quality plans for programs linked with area work plans. Accreditation under EQUIP standards. Clinical care protocols, pathways & decision tools for best practice (decision support) Merri CHS - Client Centred Care Project INW PCP Initiatives that address key improvements

17. Final Messages Change Effort Support …..the devil is in the