What is Integrated Chronic Disease Management?

• Introduction to ICDM
• IEPCP ICDM Projects
• ICDM Resources and Links

Introduction to ICDM

The goal of integrated chronic disease management (ICDM) is a coordinated health system which provides people with chronic disease with responsive, person centered, and effective care, over time throughout the different stages of disease progression.

Integrated Chronic Disease Management recognises that people with chronic disease have a complex journey to manage. This journey:

• is long-term,
• involves managing co-morbidities
• means the person needs to access significant health and community services
• crosses multiple agency and service boundaries.

Integrated chronic disease management is supported when health and community services work together with the client (and/or support person(s)) with a chronic condition to improve health, wellbeing and quality of life.

Definition of Chronic Disease

Department of Human Services defines chronic disease as “usually characterised by complex causality, multiple risk factors, a long latency period, a prolonged course of illness, functional impairment or disability and, in most cases, the unlikelihood of cure.”

The Chronic Illness Alliance defines chronic illness as "…an illness that is permanent or lasts a long time. It may get slowly worse over time. It may lead to death, or it may finally go away. It may cause permanent changes to the body. It will certainly affect the person's quality of life."

Wagner Chronic Care Model

The Wagner Chronic Care Model provides a model for system change and redesign for integrated chronic disease management. Click here to read more about models for systems approaches for integrated chronic disease management.