System reform for chronic disease
In Victoria, PCPs are funded to support ICDM through:
- service system reform and improvements (a chronic care approach to managing people with chronic disease)
- the development of integrated systems across agencies to improve the quality and coordination of care for people with chronic disease
- a focus on improving coordinated care planning, communication, information sharing and referral between health care providers
The IEPCP’s work toward a reformed system for ICDM is based on the Expanded Chronic Care Model (below). This model makes explicit the links between population health promotion and chronic disease prevention and management.
In practice, this means planning and working across a range of interdependent areas across the human services system.
Improving the Journey
The IEPCP's lead project for systems reform for ICDM is the Improving the Journey project. This project aims to improve the health and wellbeing of people with, or at risk of type 2 diabetes.
This project arose from a recognition of the need to improve the care for people with chronic disease in the Eastern Metropolitan Region (EMR). Type 2 diabetes was selected due to its significant, and growing impact on the health and wellbeing of the communities, and utilisation of services across the EMR.
The Improving the Journey project has to date focused on:
- consultations and continued engagement with consumers
- collaborating with services to conduct service reviews against
- collating data to identify needs
- developing key recommendations for change across the type 2 diabetes service system in the EMR
- developing shared tools & processes to support care
- trialling system changes through a pilot in one of the region’s local government areas, across community health, acute health (inpatient, ambulatory & outpatient services), general practice and the Royal District Nursing Service.
The next phase of the Improving the Journey project involves development of a comprehensive manual to support partners to implement system and service improvements across the region, to improve the journey for people with, or at risk of, type 2 diabetes.