Integrated Chronic Disease Management

What is Integrated Chronic Disease Management?

Integrated chronic disease management (ICDM) is a responsive, person-centred, effective system of support that aims to improve health and wellbeing outcomes and the quality of life for people with ongoing or lifelong conditions. The focus of work is at the individual level. It involves services working with each other and with those with the lived experience of the condition to ensure coordination, consistency and continuing care over time and through the different stages of a person’s condition. ICDM aims to re-orient the service system from re-active to proactive.

Service delivery and health promotion (primary and secondary) integrated approaches aim to:

  • improve service access, quality and the person’s experience of the service system
  • focus on systems and organisational change related to complex service delivery issues.

ICDM is a subset of service coordination which enables organisations to remain independent of each other, while cooperating to give consumers a seamless and integrated response. This includes local approaches to foster integration between primary health care services and other agencies, supporting practice change that will improve communication, referral and care planning. PCPs support agencies by developing partnerships, articulating roles and responsibilities, and developing care pathways.

There are some specific funded programs that support people with chronic or specific lifelong conditions:

ICDM practice principles and practice measures

The Chronic Care (Wagner) Model – Improving Chronic Illness Care is a framework developed by Ed Wagner, McColl Institute, as a system for improving outcomes for people with chronic and complex care needs.

The Chronic Care Model (CCM) identifies six fundamental areas that form a system that encourages high-quality chronic disease management. It is important to focus on all six areas, as well as developing productive interactions between clients, to enable active participation in their wellbeing, and providers, who have the necessary resources and clinical expertise.

Tools to measure improvements in chronic illness care are the Assessment Chronic Illness Care (“ACIC“, Bonomi et al., 2002) and the Patient Assessment of Chronic Illness Care (“PACIC“, The MacColl Institute, 2004) surveys.

The CCM can be applied to a variety of chronic illnesses, health care settings, and target populations.  Mental Health and Dementia are the two priority areas in which CVPCP is applying an integrated approach.

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