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Developing and Implementing a Vision for Chronic Disease Prevention and Management in South Australia Iolanda Principe Director, Primary Health Care Branch Outline South Australia Strategic Plan SA chronic disease framework An example of NSIF use in SA Systems of Care issues Models of Care

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Developing and Implementinga Vision for Chronic Disease Prevention and Management in South Australia

Iolanda Principe

Director, Primary Health Care Branch

  • South Australia Strategic Plan
  • SA chronic disease framework
  • An example of NSIF use in SA
  • Systems of Care issues
  • Models of Care
  • Approximately 80% of the total burden of disease in Australia arises from long term conditions such as CVD, diabetes, asthma, arthritis, cancers, and mental illness.
  • 51% of Australian adults in 2001 had one or more chronic diseases, which may have resulted in disability or death.
  • Heart disease, stroke, cancers and lung diseases are the underlying cause of more than 75% of all deaths in Australia.
  • 40% of South Australian adults (>447,000) have at least one of the following chronic conditions: arthritis, current asthma, CVD, current COPD, diabetes or osteoarthritis.
south austral ia s strategic plan
SouthAustralia’sStrategic Plan

South Australia’s Strategic Plan (March 2004) clearly articulates key objectives for this State over the next decade.

The plan makes specific commitment to implement recommendations of the Generational Health Review including:

  • provide health services closer to home
  • give greater priority to prevention, early intervention and health promotion
  • strengthen primary health care services
  • improve health services for the most vulnerable people in the community
  • develop a health system that focuses on the needs ofthe population rather than those of health institutions.
south austral ia s strategic plan5
SouthAustralia’sStrategic Plan


  • Growing Prosperity
  • Improving Wellbeing
  • Attaining Sustainability
  • Fostering Creativity
  • Building Communities
  • Expanding Opportunity

Objectives 2 and 6 provide specific targets for the health system.

south austral ia s strategic plan6
SouthAustralia’sStrategic Plan

Objective 2 – Improving Wellbeing

  • Increase healthy life expectancy of South Australians to lead the nation within 10 years.
  • Reduce the percentage of young cigarette smokers by 10% within 10 years.
  • Reduce the percentage of South Australians who are overweight or obese by 10% within 10 years.
  • Exceed the Australian average for participation in sport and physical activity within 10 years.
south austral ia s strategic plan7
SouthAustralia’sStrategic Plan

Objective 6 – Expanding Opportunity

  • Reduce the gap between the outcomes for South Australia’s Aboriginal population and those of the rest of South Australia’s population, particularly in relation to health, life expectancy, employment, school retention rates and imprisonment.

KeyDirectionsfor SA

Overarching Strategy

Adopt a clustered approach to chronic disease

prevention and management

Action Strategies

1. Increase system coordination and integration

2. Increase the availability of a system for self- management

3. Increase primary health care capacity for prevention, early detection, early intervention, and chronic disease management

are the nsif s useful cancer nsif into action
Are theNSIF’s useful?CancerNSIF into action
  • NSIF Cancer is being used to inform the development of the Statewide Cancer Control Plan (SCCP)
  • Principles in the National Framework have been embedded into the principles in the SCCP.
  • The NSIF Cancer has a focus on the patient journey across the continuum of care.
  • To be relevant as a framework for SA, the SCCP goes beyond this to also encompass infrastructure, workforce and also sets a cancer research agenda for SA.
statewide ca ncer control plan cancer n sif into action
StatewideCancer Control Plan:CancerNSIF into Action
  • NSIF Cancer is a high level framework for consumers, clinicians, planners and designers, policy makers, funders, professionals and managers on achieving person focused, equitable, timely and effective cancer care for all Australians.
  • SA Department of Health in collaboration with The Cancer Council SA is developing a Statewide Cancer Control Plan as a strategic planning tool to inform development and improve cancer control in SA

StatewideCancer Control Plan:CancerNSIF into action

  • In developing the SCCP, real congruency with the directions in the NSIF has been achievable:
    • a reflection of the level of consultation with the stakeholders during the development phase of the NSIF
    • also a reflection of the integrity of the consultation process in informing the final NSIF -Cancer.
  • SCCP Discussion Paper prepared by end April 2005.
  • Discussion Paper will form the basis of a consultation process being undertaken in May
  • SA SCCP completed by June 2005.
systems of care applying evidence
Systems ofCare: ApplyingEvidence

We know what is required to improve our systems of care and patient health


we don’t apply what we already know.

health care for chronic conditions what d o we know
Health carefor chronic conditions:What do we know?
  • Disease burden has changed towards chronic conditions world wide. Health systems have not.
  • Highly effective interventions exist for most chronic conditions, yet patients do not receive them.
  • Current health systems are designed to provide episodic, acute health care and fail to address self management, prevention and follow-up.
  • Chronic conditions require a different kind of healthcare (mismatch).
typical ca re the radar sy ndrome
TYPICALCARE - The RadarSyndrome

The Radar Syndrome

  • Patient appears
  • Patient is treated “find it and fix it”
  • Patient is discharged
  • … then disappears from radar screen
radar logic inappropriate care for chr onic conditions
Radar logic= inappropriate care forchronicconditions
  • System oriented to acute illness
  • Patient’s role not emphasized
  • Follow-up sporadic
  • Prevention overlooked
missed oppor tunities for clinical prevention w hat is the impact
Missedopportunitiesfor clinicalprevention:Whatis the impact?
  • Tobacco smokers have 18% higher medical charges than non-smokers
  • A one-unit increase in BMI raises medical charges by 1.9%
  • Each additional day of physical activity per week reduces medical charges by 4.7%

Study conclusions:

“Health plans that do not systematically support members’ efforts to improve health related behaviours may be incurring significant short-term health care charges that may be at least partly preventable.” JAMA. 1999; 282: 2235-9

chronic co nditions require an evolution of health care
Chronic conditionsrequire an evolutionof health care…

…….from typical (radar care) to achievable Innovative Care

  • No longer is each risk factor and chronic illness being considered in isolation.
  • Awareness is increasing that similar strategies can be equally effective in treating many different conditions.
  • Organised systems of care, not simply individual health care workers, are essential in producing positive outcomes.
conceptual frameworks for chron ic disease
ConceptualFrameworks forChronicDisease
  • A range of conceptual frameworks have been developed for the prevention and management of chronic disease
  • A “whole of system” approach is required to be effective
  • For successful implementation, an active change management process is required

Wagner Chronic Care Model 1997


Health System

Resources and Policies

Health Care Organizations




Self-Management Support





Practice Team






Improved Outcomes

wagner chronic care model elements
Wagner Chronic CareModel Elements
  • Self-management support: Empower and prepare patients to manage their health and health care.
  • Delivery system design: Assure the delivery of effective, efficient clinical care and self-management support.
  • Decision support: Promote clinical care that is consistent with scientific evidence and patient preferences.
  • Clinical information system: Organize patient and population data to facilitate efficient and effective care.
  • Health care organization: Create a culture, organization and mechanisms that promote safe, high quality care.
  • Community: Mobilize community resources to meet needs of patients.
nsw chronic care model 2004

Positive Policy Environment

Community Resources & Services


Patient and

Family / Carer

Centred Care

Health Care Organisation







Improved health outcomes

For people with chronic disease

NSWChronicCare Model 2004

Reference: Modified from World Health Organisation and Wagner and Colleagues

issues to be given further considera tion today
Issues to be given further consideration today….
  • How can a systematic quality improvement process be incorporated into current chronic disease developments in SA?
  • How can a systematic process to develop service standards for the prevention and management of chronic disease be created?
  • How can a systematic process to develop/adopt evidence based guidelines for the prevention and management of key chronic diseases be created?