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South Australian Chronic Disease Action Plan

SA Health> Responding to the challenge ofchronic disease• greater focus on ongoing careacross disease continuum• prevention• early intervention• disease management• self management support• case management


Chronic Disease Action Plan> Chronic Disease Action Plan outlines SA Health’sten year plan to address preventable chronic disease> Updates the 2004 strategy: ‘Chronic Disease:Prevention and Management Opportunities for SouthAustralia’> Aligns with the priorities of the National ChronicDisease Strategy 2005> The Plan is a part of the health sector reformprocess led by the South Australian Health CarePlan 2007 – 2016> Address specific priority group needs includingAboriginal and Torres Strait Islander, Culturally andLinguistically Diverse, low socio-economic


Health Equity focus35.030.025.0Rate of mortality per 1,00020.015.010.05.00.0Ischaemic heart disease Type 2 diabetes Stroke COPD Other chronic respiratoryIndigenousNon-indigenous


Chronic Disease Action PlanOverarching Vision• Prevent chronic disease, by reducingrisk associated with biomedical andlifestyle factors• Detect disease and risk of disease earlyand intervene early and effectively• Manage existing disease effectively andproactively.


Chronic Disease Strategies> Prevention• Focus on secondary and tertiary prevention methods• Primary prevention methods will be addressed inupcoming Primary Prevention Plan> Early Intervention• Screening, use of validated risk assessment tools• Monitoring - registers for risk factors• Risk factor modification programs> Early Detection• Detect disease early• Monitoring - registers for chronic disease


Chronic Disease Strategies> Disease Management• partnerships across all care settings• care planning• multidisciplinary/team based care• improve transitions between care providers• improve management of complex conditions & comorbidities> Self Management Support• supported in all health encounters for people withchronic disease through training and education ofproviders• referral to self management programs• referral to disease specific self care programs


Key Outcomes and ActionsOutcome 4: Improve self managementsupport> Education and training> Support referral of self managementprograms> Availability of culturally appropriate selfmanagement programs


Self Management Support> Involves health professionals assisting individualswith chronic disease to:• engage in activities that protect and promote health• monitor and manage the symptoms and signs of illness• manage the impact of illness on functioning emotionsand interpersonal relationships• adhere to treatment regimes> Self Management Support Promotes:• the patients central role in their health care• collaborative care planning• targeting and goal setting• action planning• referral to specific programs where appropriate andorganised follow-up


Self Management Programs> Self Management programs/approaches include:• Stanford Self Management Program• Flinders Self Management Program & Tools• 5 A’s (Assess, Advise, Agree, Assist, Arrange)• Health Coaching and Motivational Interviewing• Living Improvements for Everyone (L.I.F.E.)Program> Unique to SA:• Do it For Life - Flinders Model adapted forassessing and managing preventable/modifiable(SNAPS) chronic disease risk factors


Chronic Care> Chronic Care describes a partnership approach tointegrating long term chronic disease client careacross primary health care, public hospitalsystems and in partnership with clients> Applications across primary health care, subacuteand acute settings, regardless of public orprivate funding> Focused on people with diagnosed chronicdisease and integrating self management supportinto routine care


Chronic Care> Agreed Health Care Plans in accordance with theChronic Disease Action Plan acts as both acommunication tool and a coordination toolbetween the client and health professionals> The aim is to develop a living document thatsupports planned health maintenance andappropriate escalation responses> Some types of care plans already exist such asGP Care Plans & Team Care Arrangements;Flinders Chronic Care Plans; Asthma Action Plansfor children and young people


ChallengesTo engage all health care professionalsthrough self management supporteducation and training to:• incorporate self management principlesinto routine care• address inconsistency in clinical pathways• shift the balance of care to the patient/client• develop a sustainable workforce that canrespond to the changing health careenvironment


Opportunities• Political climate that supports change• System level change is both possibleand is being supported by SA Health• Support from the Regions to developconsistent programs & services• Self management educationprogressively incorporated intoundergraduate training (both tertiaryand TAFE)• Give clients real opportunities to beactive in decision making


Future directions> Increased use of electronically sharedAgreed Health Care Plans> Increased support for and fromorganisations and Health Professionalsaround self management activities orprograms> Live up to the promise of deliveringclient centred care


Summary> Chronic diseases exert considerable andgrowing pressure on the SA Health System> The Chronic Disease Action Plan outlinesevidence based approaches to improve, inall health settings:• early intervention• chronic disease secondary prevention• chronic disease management, and• self management support of chronic disease> The Plan is the 10 year blueprint for action onchronic disease in South Australia


For further informationBRUCE WHITBYManager, Out of Hospital Strategies &Chronic Disease StrategiesStatewide Service Strategy DivisionSA HealthPHONE: (08) 8226 6020EMAIL: bruce.whitby@health.sa.gov.au

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