Improving outcomes for people with chronic disease
Chronic conditions are the leading cause of illness, disability and death in Australia. Common chronic conditions include diabetes, heart disease and respiratory disease. Chronic conditions are becoming increasingly common due to our ageing population, as well as our changing lifestyles1.
Chronic care services in Western NSW Local Health District include programs related to:
Some chronic conditions are not preventable because they are genetic or the cause is unknown. Examples include type 1 diabetes, multiple sclerosis, rheumatoid arthritis and cystic fibrosis.
Other chronic conditions can develop due to risk factors that people can control. Examples include type 2 diabetes, kidney disease, some lung diseases, and many cardiovascular conditions.
Focusing on prevention can significantly reduce the number of people affected by preventable chronic conditions, as well as the severity of those conditions. This can help lead to better health outcomes and long-term cost savings.
Things you can do to reduce the risk of developing a preventable chronic condition include:
- Quitting smoking
- Getting enough physical activity
- Reducing your alcohol intake
- Eating well
- Maintaining a healthy weight
- Maintaining healthy blood pressure
- Having good cholesterol levels
Strategies to effectively manage chronic conditions can help minimise complications and associated disabilities, and to optimise quality of life. Several programs and resources are available within the Western NSW Local Health District for chronic disease management.
Cardiac and Pulmonary Chronic Disease Rehabilitation Programs
These programs run throughout WNSWLHD and provide identification of risk factors and risk factor reduction, education, exercise and self-management. Programs are usually between 6 and 8 weeks duration. A GP referral is required for these programs.
Diabetes Educator services
These services provide comprehensive assessment and specialised management of patients with Type 1, 2 and Gestational diabetes who need a higher level of support than the GP can provide. A GP referral is required for these services.
Smoking Cessation Support
Did you know that using stop smoking medications (such as nicotine replacement therapy), as well as behavioural support from Quitline, is the best way to quit and stay quit? Give yourself the best possible chance of success by using a combination of stop smoking medications as well as a quit smoking support service.
Talk to your General Practitioner (GP) or pharmacist and ask them about accessing low cost nicotine replacement patches, gum or lozenges, or other stop smoking medications.
The NSW Quitline is a free and confidential telephone service providing customised assistance to help you with your quit smoking attempt. The trained counsellors can provide you with tips and strategies on how to quit and help you to manage triggers, cravings and withdrawals. You can access the Quitline by calling 13 7848 (13 QUIT), or if preferred, make an online request for a NSW Quitline call-back.
Intensive smoking cessation service
This service is for people who are heavily addicted to smoking and have previously tried to quit with Quitline and GP support. The program includes comprehensive assessment, identification of smoking triggers, pharmacotherapy and intensive behavioural support. A GP / health professional referral is required.
Planned Care for Better Health program (PCBH)
BCBH identifies people who may be at increased risk of having to go to hospital, and offers assessment and support to help keep them healthier for longer. Support might include holistic patient assessment and service navigation.
Respiratory Coordinated Care Program (RCCP)
RCCP is offered from Orange and Bathurst for patients with moderate to severe respiratory disease who are at risk of hospitalisation. The aim of the program is to provide care in the home and to treat exacerbation early to minimise avoidable admissions.
1. Australian Health Ministers’ Advisory Council, 2017, National Strategic Framework for Chronic Conditions. Australian Government. Canberra.
Who can refer?
- Public and Private Hospitals and other services
- Health Care workers
- General practitioners and medical specialists
- Government and non-government organisations
- Members of the community
Integrated Care in the Community programs include:
- Planned Care for Better Health
- Remote in Home Monitoring
- COVID Care in the Community
- Collaborative Commissioning – Care Partnership Diabetes
The Regional Intake Centre helps link people with the right health service for their care. Referrals can be made during business hours.
Planned Care for Better Health is a free program for people over the age of 16 years with chronic and complex health conditions. PCBH offers a 12 week model of care responsive to each persons individual, holistic care needs.
Care coordinators help people manage their health conditions through health coaching, coordination of the health care services they need, and by helping them navigate the health and social care system.
What we do
Our Integrated Care Coordinators work with you and your doctor to develop a health plan that meets your needs. The service supports people over the age of 16 to:
- Learn more about your health problem
- Assist you to better understand and manage your health
- Connect you to a GP and talk with your doctor and other health services
- Understand how to take your medications and why you take them
- Link you with services and support to help you manage your condition and stay at home
- Provide a culturally appropriate service with the support of Aboriginal Health Practitioners
What to expect
If you are referred to our Integrated Planned Care for Better Health program one of our care coordinators will:
- Undertake a comprehensive health assessment with you in your home, in one of our clinics, or virtually
- Set goals in partnership with you
- Help you and your carer with your health and social care needs through education, navigation and coordination
- Help you improve your connection and collaboration with health and social care providers
- Work with you, your GP and other healthcare professionals to develop a Care Plan including:
- A list of the health professionals you see and what they do for you
- Other services you may be receiving and how they help you
- Information about your medications
- What you can do to stay healthy at home
- Carer information
If you have recently been in hospital or to an emergency department in the Western NSW Local Health District, we can also use this information to support PCBH activities.
How to access Integrated Care – Planned Care for Better Health
Health professionals can refer you to BCBH, or you can make contact with us directly to talk about whether you are eligible. Referrals are accepted during business hours
Integrated Care Central Intake
Planned Care for Better Health Manager
The Remote in-Home Monitoring (RiHM) service aims to improve in-home support and to prevent hospitalisation of people in two key target groups:
- People with an acute illness, such as COVID-19 or other acute conditions
- People with sub-acute and/or chronic and complex health and social conditions
People enrolled in RiHM have 7-day a week access to registered nurse/midwife remote monitoring support. RiHM works in partnership with the person (and their carer) and local healthcare clinicians to provide goal-based care coordination and health coaching. RiHM uses virtual care or remote technology to optimise local face to face health service and aims to improve client/carer and local clinician experience, health outcomes and the effectiveness and efficiency of care.
People in their home are provided with the technology and clinical support to take their own health measurements such as blood pressure, pulse oximetry, weight, blood glucose, and temperature. These measurements, in addition to regular answers to health questions tailored to person’s health condition are monitored 7 days a week by nurses using a remote clinical dashboard. Patient results are triaged and responded to, with escalation set out in patient care plans. Reports of trending information are sent to local clinicians to assist with care planning. Patients also have access to their results on their iPhone or a supplied iPad and are able to use this information to when talking with their GP, specialist or other healthcare provider.
CCiC provides clinical care and support for people in the Western NSW Local Health District with COVID-19 who are at higher risk of COVID-related complications as a result of their health condition or medical history. The majority of people with COVID-19 can safely manage their symptoms at home with support from their GP and other primary care providers.
People admitted into CCiC because of their increased risk have access to a multidisciplinary team of medical, nursing and allied health professionals.
Nurses (Endorsed, Enrolled & Registered nurses) provide virtual monitoring of COVID-19 positive patients in their home (or other accommodation). Patients are generally contacted daily depending on their health condition to provide clinical assessment, support and monitoring.
Remote in home monitoring (RiHM) kits are provided to COVID-19 positive patients as needed based on clinical condition. These kits include a pulse oximeter, thermometer and an information booklet for patients and carers. Measurements and daily health surveys are able to be uploaded to a dashboard which is monitored by registered nurses. This platform also facilitates secure video conferencing between patients and clinicians.
Allied Health including Social Work, Occupational Therapy and Dietitian help ensure people with COVID-19 are well supported at home.
Medical Officers provide virtual medical consultations as needed following assessment by a Nurse. Virtual Medical Officers also work closely with local health facilities to organise in-person assessments at an Emergency Department when people are struggling to manage their COVID-19 symptoms at home.
24/7 care is available for people enrolled in the CCiC program via the District’s COVID Care in the Community Call Centre.
If you have COVID-19 and require additional information or support and have not been contacted by the WNSWLHD CCiC team please contact the State COVID helpline on 1800 020 080.
CCiC aims to keep people at higher risk from COVID-19 complications well supported in the community to avoid unnecessary visits to hospital.
Collaborative Commissioning is one of four of NSW Health’s flagship value-based healthcare initiatives that supports local partnerships to deliver more co-ordinated, patient centred care in the community.
Care Partnership – Diabetes brings together Western NSW and Far Western Local Health Districts, the Western Primary Health Network and NSW Rural Doctors Network in a partnership to identify and support people with Type 2 Diabetes and apply the collaborative commissioning model to improving a ‘one health system’ mindset. Type 2 Diabetes has been selected as the focus for this action due to its high prevalence, significant implications for health and wellbeing, and the potential for marked improvements in coordinated and integrated care across region.