1. Working together - a healthy partnership Knox Improving Chronic Care Project The preparations required to implement an effective chronic disease program Kate Gilbert, Chronic Disease Project Manager

2. Working together - a healthy partnership Knox Community Health Service The Early Intervention in Chronic Disease Initiative

3. Working together - a healthy partnership Local systems and organisational development – links with GPs (referral systems, care planning, team care arrangements) – internal: assessment tools, referral processes, prioritisation, self-management training – support neighbouring CHSs Service delivery – new clinical areas to respond to community – ‘key workers’/named contacts – self-management interventions/groups – psychosocial / psychology $400,000 per year recurrent + $167,000 establishment Scope of EIiCD

4. Working together - a healthy partnership Knox Community Health Service Identifying target groups and priorities

5. Working together - a healthy partnership Knox Community Health Service Consultation Timeline NOVEMBER 4 x Consumer Focus Groups Facilitated by Chronic Illness Alliance DECEMBER OCTOBER Collect Data – Prevalence Key Stakeholders’ Forum GP Phone Interviews Preliminary consultation local consumer groups Convene Internal Reference Group Internal Chronic Disease Screening Exercise Dental Service Chronic Disease Audit Internal Client Sat. Survey Implem. Planning Pres. to DHS Client-specific Internal GPs and other external stakeholders Implem- entation Plan to DHS Mapping self-management interventions Consumer Focus Groups continued

6. Working together - a healthy partnership Knox Community Health Service PHIDU - Population health profiles by Division of GP: www.publichealth.gov.au Department of Human Services (2006). Ambulatory Care sensitive conditions 2004-05 update – by Region. Burden of Disease - Disability Adjusted Life Years: http://www.aihw.gov.au/cdarf/index.cfmhttp://www.aihw.gov.au/cdarf/index.cfm HARP – Local hospital admission data Local Council, Social Researcher

7. Working together - a healthy partnership Knox Community Health Service Number of people in Knox (estimated) Reference: PHIDU. (2005) Population health profile of the Knox Division of General Practice. Population Profile Series: No. 50. Public Health Information Development Unit (PHIDU), Adelaide.

8. Working together - a healthy partnership Knox Community Health Service Summary MeasureHighest in KnoxHigher than comparison populations Estimated number of people living with each chronic disease, 2001 COPD & other Chronic Respiratory (exc. Asthma) COPD & other Chronic Respiratory (inc. Asthma) Disability Adjusted Life Years (DALYs), 2001 Cardiovascular Disease (inc. ischaemic & stroke) All comparable Premature mortality, 2000-02 Heart failure and other CVD (exc. ischaemic & stroke) Diabetes Respiratory diseases Preventable Hospital admissions, 2004-05 Diabetes Cellulitis Emergency department admissions, 2005-06 Asthma State-wide data for 2005-06 not yet available

9. Working together - a healthy partnership Knox Community Health Service Chronic Disease in Knox Chronic Respiratory Diseases (COPD etc) - most prevalent chronic condition in Knox, even when asthma not counted Chronic Respiratory Diseases and Asthma - prevalence is >10% above Australian average rate in north of Knox, and 5-10% above in south Knox When comparing chronic diseases: Cardiovascular disease - greatest contributor to premature mortality and DALYs Diabetes - leading cause of preventable hospital admissions (Ambulatory Care Sensitive Admissions Study) Asthma highest cause of ED admissions in Knox

10. Working together - a healthy partnership Knox Community Health Service One Day Snapshot Dental Clients Which chronic conditions did the clients have?

11. Working together - a healthy partnership Knox Community Health Service 1 week – 252 clients, 95 with chronic disease

12. Working together - a healthy partnership Knox Community Health Service Is there anything we can do in …. arthritis?

13. Working together - a healthy partnership Knox Community Health Service Knox – Target Groups 1.Respiratory Disease > Newly-diagnosed COPD 2.Diabetes > Type 2 diabetes Insulin Initiation 3.Musculoskeletal > Osteoarthritis Pathway 4.Heart Disease > Cardiac Rehabilitation

14. Working together - a healthy partnership Knox Community Health Service Further findings – after target groups determined

15. Working together - a healthy partnership Knox Community Health Service Overview of Knox population Mapping self-management interventions in the Outer East

16. Working together - a healthy partnership Knox Community Health Service Nature Generic/Evidence-based/Stanford model/ Better Health Self-Management – 2 Disease-specific: –MSK – 8 –Cardiac – 5 –Pulmonary rehabilitation – 3 –Diabetes education – 5 –Cancer – 2 –Multiple sclerosis – 1 –Weight loss – 2

17. Working together - a healthy partnership Knox Community Health Service

18. Working together - a healthy partnership Knox Community Health Service KCHS Screening Exercise November 2006 Dental File Audit November 2006 PHIDU Population Estimates for Knox Arthritis57% 33%16,160 Heart disease26% 20,137 Type 2 Diabetes25% 17%2,468 Asthma21% 33%18,396 Stroke7% 9% Lung/ Respiratory 5 % 3%29,078 Type 1 Diabetes3% 840

19. Working together - a healthy partnership Knox Community Health Service Consumer involvement Focus Groups – CIA Client Satisfaction Survey – piggy back Reference Group – consumer reps Community resources and linkages: Informal – local support groups Establishing partnership arrangements Delegated ‘Community expert’ on staff Pathways – ongoing support

20. Working together - a healthy partnership Cardiac Rehab Phase 3 Newly-diagnosed COPD Type 2 Diabetes Insulin Initiation Osteoarthritis Hip or Knee Spirometry services / GPs Angliss Rehab, HARP GPs (existing referral stream) KCHS Case-finding and internal referral Angliss Hospital and GPs (existing referrals) KCHS INTAKE: 1. SCTT 2. CDM introduction 3. Key Worker identification Assessment: inc. Partners in Health Scale, Baseline Evaluation Allocate to Key worker Individualised Care Plan: Flinders Goal Setting & Evidence Based Pathways Follow-up: Telephone coaching or individual consults Individual services Dental, Physio, OT, Podiatry, Psychology, Counselling Diabetes Ed Community linkages Physical Activity, Socialisation support, Lifestyle management, Psychosocial support, Self-help groups Group programs Stanford course, Pulmonary rehab, DAFNE Diabetes education, Falls prevention, Tai-Chi for arthritis, CVD Phase 3, etc. Psychologist case review and treat directly or extra support to key worker Mental health condition identified Scheduled Recall and Review & 6-monthly evaluation surveys GP: Intro & Clinical data for evaluation GP: Detail Care Plan Patient-held record GP: Revisions to Care Plan or 6 months Target Groups & Referral Sources 1 s YEAR EI Referrals to HARP Eastern HARP ACCESS Review assessments already completed to avoid duplication Assume existing clients already had SCTT etc