Working together - a healthy partnership Knox Improving Chronic Care Project The preparations required to implement an effective chronic disease program

Working together - a healthy partnershipKnox Improving

Chronic Care Project

The preparations required to implement an

effective chronic disease program

Kate Gilbert, Chronic Disease Project Manager

Knox Community Health Service

Working together - a healthy partnership

The Early Intervention in Chronic Disease Initiative


• 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



Identifying target groups and priorities



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-specificInternalGPs and other external stakeholders

Implem-entation

Plan to DHS

Mapping self-management interventions

Consumer Focus Groups continued



• 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.cfm

• HARP – Local hospital admission data• Local Council, Social Researcher



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.

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10,000

20,000

30,000

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SummaryMeasure Highest in Knox Higher 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



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



One Day Snapshot Dental Clients

Which chronic conditions did the clients have?

Blood pressure,

27%

Arthritis, 26%Heart

disease, 15%

Diabetes, 9%

Stroke, 9%

Asthma, 2%

Brain tumours, 2%

Fits, 2%Hep C, 2%



1 week – 252 clients, 95 with chronic disease

Asthma, 33%

Blood pressure,

31%

Heart disease,

26%

Diabetes, 17%

Arthritis, 33%

Stroke, 9%

Emphysema, 3%

Epilepsy/Fits, 4%

Hep B, 1%Parkinsons,

1%Hep C, 6%



Is there anything we can do in …. arthritis?


Working together - a healthy partnershipKnox – Target Groups

1. Respiratory Disease > Newly-diagnosed COPD

2. Diabetes> Type 2 diabetes Insulin Initiation

3. Musculoskeletal > Osteoarthritis Pathway

4. Heart Disease > Cardiac Rehabilitation



Further findings – after target

groups determined



Overview of Knox population

Mapping self-management interventions in the Outer East


Working together - a healthy partnershipNature

• 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





KCHS Screening Exercise November 2006

Dental File Audit November 2006

PHIDU Population Estimates for Knox

Arthritis 57% 33% 16,160

Heart disease 26% 26% 20,137

Type 2 Diabetes 25% 17% 2,468

Asthma 21% 33% 18,396

Stroke 7% 9%

Lung/Respiratory

5 % 3% 29,078

Type 1 Diabetes 3% 840


Working together - a healthy partnershipConsumer 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


Cardiac RehabPhase 3

Newly-diagnosed COPD

Type 2 DiabetesInsulin Initiation

OsteoarthritisHip or Knee

Spirometry services / GPsAngliss 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 servicesDental, Physio, OT, Podiatry,

Psychology, CounsellingDiabetes Ed

Community linkagesPhysical Activity, Socialisation support,

Lifestyle management, Psychosocial support, Self-help groups

Group programsStanford course, Pulmonary rehab, DAFNE

Diabetes education, Falls prevention, Tai-Chi for arthritis, CVD Phase 3, etc.

Psychologist case reviewand 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

Tar

get G

roup

s &

Ref

erra

l Sou

rces

1s

YE

AR EI Referrals to HARP

Eastern HARP ACCESS

Review assessments already completed to avoid duplication Assume

existing clients already had SCTT etc

Documents

Working together - a healthy partnership Knox Improving Chronic Care Project The preparations required to implement an effective chronic disease program