CHRONIC DISEASE MANAGEMENT

Chronic Disease Management

A whole practice patient-centred approach.

Chronic disease is one of the leading causes of illness, disability, and death in Australia. Chronic medical conditions are those that have been, or are likely to be, present for at least 6 months. This includes asthma, cancer, cardiovascular disease, diabetes, kidney disease, musculoskeletal conditions, and stroke.

Chronic Disease Management is essential to both improving health outcomes of individuals and containing costs in the health care system. The introduction of a Chronic Disease Management Plan by the practice, can provide an organised approach of care that can assist patients with chronic medical conditions.

Chronic conditions – From cure to care

Chronic conditions are now the leading cause of death and disability worldwide. Disease rates from these conditions are accelerating globally and impacting all socioeconomic classes. This has shifted the focus for health services from ‘cure’ to health ‘care’.

15 chronic conditions pose a significant burden in terms of morbidity, mortality and health care costs in Australia, and importantly, are amenable to preventive measures:

Chronic Conditions

From cure to care

15 chronic conditions pose a significant burden in terms of morbidity, mortality and health care costs

coronary heart disease
stroke
asthma
lung and colorectal cancer
depression
type 2 diabetes
Rheumatoid Arthritis
Osteo Arthritis Diabetes Mellitus
cardiovascular disease
Hypercholesterolemia
osteoporosis
chronic obstructive pulmonary disease (COPD)
chronic kidney disease
oral disease
Chronic Pain management and many more.

Supporting self-management can assist to optimise their use of healthcare resources such as avoiding unnecessary visits to hospital.

Determinants for chronic conditions

Determinants are factors that can influence how likely people are to stay well or become ill or injured. Determinants can have a positive or negative impact on chronic conditions.

Those that have a positive effect are often referred to as protective factors. Those that have a negative effect are commonly referred to as risk factors.

Some determinants are modifiable, such as behavioural risk factors such as smoking, excess alcohol, inactivity, poor diet. Biomedical factors that are modifiable are excess weight, high blood pressure and blood cholesterol.

Non-modifiable factors include:

age
gender
indigenous
ethnic background
family history
genetic makeup.

Other broad influences for chronic conditions include:

socio-economic
psychosocial
early life
political factors.

Many chronic conditions are preventable, as well as respond more favourably to management and medical treatment in people who adopt healthy behaviours, such as:

controlling body weight
eating nutritious foods
avoiding tobacco use
limiting alcohol intake
increasing physical activity.

Self-management strategies can be used to target modifiable risk factors and build the capacity and confidence to adopt healthier lifestyles. These strategies include behaviour change approaches, shared decision-making, goal setting and person-centred care.

CHRONIC DISEASE MANAGEMENT

CHRONIC DISEASE MANAGEMENT