Sustaining chronic disease management in primary care: lessons from a demonstration project.

Chronic disease self-management (CDSM) programs have been found effective in improving clinical, behavioural, and self-efficacy outcomes associated with a range of chronic illnesses, and evidence suggests that CDSM is effective in reducing health care costs and health service utilisation. As the setting where most chronic disease is managed, primary health care is an ideal setting for supporting CDSM. This study aimed to explore the uptake and sustainability of CDSM within routine activities of primary health care clinicians involved in the implementation of a demonstration project within an Area Health Service in Sydney NSW. Interviews and focus groups were conducted with managers and clinicians involved in the project. Findings included (1) widespread support from participants for CDSM (2) participating clinicians thought that CDSM was valuable to themselves, their clients and the health system (3) the program required clients to be able to speak and understand English and so presented many barriers for implementation in CALD communities, and (4) the program was not effective in engaging some key members of the primary care team; in particular, general practitioners. The study highlights system design issues including communication and continuity of care between service providers, workforce supply and demands of acute care delivery in the community that will need to be addressed for sustainable and effective CDSM to be achieved

A systematic review of chronic disease management

This is the final report of a systematic review conducted as part of the Australian Primary Health Care Research Institute (APHCRI) Stream Four funding. The aim of Stream Four was to systematically identify, review, and synthesise knowledge about primary health care organisation, funding, delivery and performance and then consider how this knowledge might be applied in the Australian context. This particular review focussed on the management of chronic diseases in the primary care setting

Linked Care Evaluation Hornsby Ku-ring-gai Coordinated Care Trial, Local Evaluation Service Provider Experience Report

The Linked Care Trial was an innovative approach to linking health and community care services for people in need of ongoing care, established in 1996-97 in the municipalities of Hornsby and Ku-ring-gai in Sydney’s northern suburbs. The trial formed part of a national program of Coordinated Care Trials established in 1996 to test whether it is possible to coordinate the care currently provided by a variety of different health and community care services and practitioners using funds pooled from a number of different Commonwealth and State programs. This flexible use of funding was to be managed by care coordinators (CCs) assigned to each participant, using an individual care plan to help organise the medical care and social assistance that each would receive. The Evaluation of the Linked Care Trial was to test whether this approach could be practically implemented in the local community and, if so, to determine whether this led to a more effective use of existing resources with improved outcomes for participants and caregivers. This service provider experience thematic report reviews progress with Linked Care and the evaluation from commencement of the Live Phase of the trial in 1997 to its formal conclusion in December 1999. Drawing on quantitative and qualitative data collected as part of the Local Evaluation, the report presents an analysis of findings with respect to a number of separate components of Linked Care. It also identifies the conditions which underlie the achievements of Linked Care in this period and considers obstacles that have constrained the achievement of trial goals or which could have affected the evaluation. Service providers were integral to Linked Care as partners in Linked Care management, contributors to the fund pool, subcontractors of care coordination services and the providers of health and community care to the participants

Linked Care Evaluation Hornsby Ku-ring-gai Coordinated Care Trial, Local Evaluation Client Experience Report

The Linked Care Trial was an innovative approach to linking health and community care services for people in need of ongoing care, established in 1996-97 in the municipalities of Hornsby and Ku-ring-gai in Sydney’s northern suburbs. The trial formed part of a national program of Coordinated Care Trials (CCTs) established in 1996 to test whether it was possible to coordinate the care currently provided by a variety of different health and community care services and practitioners using funds pooled from a number of different Commonwealth and State programs. This flexible use of funding was to be managed by care coordinators (CCs) assigned to each participant, 1 using an individual care plan to help organise the medical care and social assistance that each would receive. The local evaluation of the Linked Care Trial was to test whether this approach could be practically implemented in the local community and, if so, to determine whether this led to a more effective use of existing resources with improved outcomes for participants and caregivers. This client experience report reviews progress with Linked Care and the evaluation, from commencement of the live phase of the trial in 1997 to its formal conclusion in December 1999. Drawing on quantitative and qualitative data collected as part of the local evaluation, the report presents an analysis of a number of components of Linked Care from the perspective of participants

Linked Care Evaluation Hornsby Ku-ring-gai Coordinated Care Trial, Local Evaluation Report

The Linked Care Trial was an innovative approach to linking health and community care services for people in need of ongoing care, established in 1996-97 in the municipalities of Hornsby and Ku-ring-gai in Sydney’s northern suburbs. The trial formed part of a national program of Coordinated Care Trials (CCTs) established in 1996 to test whether it was possible to coordinate the care currently provided by a variety of different health and community care services and practitioners using funds pooled from a number of Commonwealth and State programs. This flexible use of funding was to be managed by care coordinators (CCs) assigned to each participant, 1 using an individual care plan to help organise the medical care and social assistance that each would receive. The local evaluation of the Linked Care Trial was to test whether this approach could be practically implemented in the local community and, if so, to determine whether this led to a more effective use of existing resources with improved outcomes for participants and caregivers. This final evaluation report reviews progress with Linked Care and the evaluation from commencement of the Live Phase of the trial in 1997 to its formal conclusion in December 1999. Drawing on quantitative and qualitative data collected as part of the local evaluation, the report presents an analysis of findings with respect to a number of separate components of Linked Care. It also identifies the conditions which underlie the achievements of Linked Care and considers obstacles that constrained the achievement of trial goals or which could have affected the evaluation

Linked Care Evaluation Hornsby Ku-ring-gai Coordinated Care Trial, Local Evaluation Whole of System Report

The Linked Care Trial was an innovative approach to linking health and community care services for people in need of ongoing care, established in 1996-97 in the municipalities of Hornsby and Ku-ring-gai in Sydney’s northern suburbs. The trial formed part of a national program of Coordinated Care Trials (CCTs) established in 1996 to test whether it was possible to coordinate the care currently provided by a variety of different health and community care services and practitioners using funds pooled from a number of different Commonwealth and State programs. This flexible use of funding was to be managed by care coordinators (CCs) assigned to each participant, 1 using an individual care plan to help organise the medical care and social assistance that each would receive. The local evaluation of the Linked Care Trial was to test whether this approach could be practically implemented in the local community and, if so, to determine whether this led to a more effective use of existing resources with improved outcomes for participants and caregivers