Key messages

  • Health services in Victoria provide care to people with chronic disease.
  • Service improvements to achieve ICDM are underpinned by the Improving Chronic Care (Wagner) Model and guided by the 2008 Revised Chronic Disease Management Program guidelines.
  • The vision for ICDM is a responsive, person-centred, effective system of care that aims to improve health outcomes and the quality of life for people with chronic disease.
  • The department has resources to help service providers implement ICDM.

Chronic disease

Chronic diseases affect the quality of life of many Victorians, and can lead to disability and premature death. They also account for a large share of Victoria’s healthcare costs.

Chronic diseases can develop and progress differently among people affected, but they have similar characteristics:

  • their cause can be complex, involving many risk factors
  • they may take a long time to develop
  • they result in a long illness, which often cannot be cured
  • they can lead to functional impairment or disability.

Integrated chronic disease management

Effective chronic disease management uses a model of shared care that engages people with a chronic disease as well as service providers.

The vision for integrated chronic disease management (ICDM) is the delivery of a responsive, person-centred, effective system of care that can improve health outcomes and quality of life for people with chronic disease. The aims are to:

  • slow the rate of disease progression while maximising health and wellbeing
  • improve access to quality, integrated multidisciplinary care
  • facilitate client and carer empowerment through self-management programs and approaches
  • actively engage general practitioners as part of a multidisciplinary coordinated approach
  • reduce inappropriate demands on the acute health care system.

ICDM includes:

  • identifying client needs early, leading to appropriate and timely referrals
  • coordinating care using team-based approaches, possibly across multiple organisations
  • evidence-based care
  • support for self-management
  • regular review and follow-up
  • Victorian health services involved in ICDM

In Victoria, service organisations working in this area aim to deliver a responsive, person-centred, effective system of care that can improve health outcomes and quality of life for people with chronic disease.

Primary Care Partnerships (PCPs) promote and facilitate coordinated local approaches to improve ICDM 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.

PCPs use the Improving Chronic Care (Wagner) Model framework to develop a service system for improving the care of clients with chronic and complex care needs.

All community health services in Victoria provide care to people with chronic disease and are involved in ICDM work. The community health chronic disease management program is flexibly funded to deliver nursing, allied health and counselling services to people with chronic and complex needs. Community health services also deliver ICDM through specific allocations and resources, such as Early Intervention in Chronic Disease (EIiCD) programs.

The 2008 Revised Chronic Disease Management Program guidelines direct and support effective care for people with chronic disease. The 2008 program guidelines are currently being updated and are expected to be released in 2015.

The FAQs about community health data reporting help service providers working with general practitioners (GPs) funded through Medicare Benefits Schedule (MBS) chronic disease management (CDM) items.