The Wagner Chronic Care Model, with its six interdependent elements, provides the framework for Primary Care Partnerships to develop a service system for improving the care of clients with chronic and complex care needs.
An online Wagner Chronic Care toolkit provides step-by-step descriptions of the specific changes involved in Chronic Care Model implementation, including tools, strategies to address financial and operational barriers to quality improvement, and case studies of successful quality improvements and service system developments to improve chronic care.
Early Intervention and Integrated Care (EI & IC) includes the following:
- Assisting healthcare staff in the management of their patients with chronic illnesses to improve their quality of life and delay disease progression.
- Coordinating services between and within health organisations for patients who require more than one service. Referrals, multidisciplinary team meetings, and care pathways may assist in service coordination and chronic disease management.
- Planned and proactive care intended on keeping people as well as possible rather than responding to an illness.
- Empowering, systematic, and coordinated care that includes regular review, support for self management, and assistance to make lifestyle and behaviour changes.
- Care that is provided by a range of health services and practitioners (eg. GPs, podiatrist, physiotherapist, counsellor, dietitian, nurse, specialist, dentist).
- Care that is provided over time through the stages of disease progression and with coordinated follow-up.
Primary Care Partnerships (PCPs) promote and facilitate coordinated local approaches to improve integrated chronic disease management and coordination of services for people in their communities. They 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.
Current projects that the EGPCP are involved with to improve early intervention and integrated care in East Gippsland include the following:
- The Gippsland Guide to Becoming a Health Literate Organisation
- Health Pathways Project (lead by Gippsland Primary Health Network)
- Service Coordination Survey
- Assessment of Chronic Illness Care
- S2S referral system