Supporting PHNs to deliver effective chronic disease management programs

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Though some providers and consumers work very well together to manage chronic illness, intractable problems remain in Australia that PHNs and others are working to address. Here are some bare facts for reflection:

  • Over 50% of Australians aged 45 and over have a chronic condition.
  • Much to our surprise, a new Australian Institute of Health and Welfare report showed only 16% of adults accessed chronic disease management (CDM) care plans via their GPs, and the majority did not access the Medicare-subsidised allied health visits these plans unlock. 
  • We also know that not all GP care plans are useful for patients – published evidence states that GP care plans are much more likely to assist patients if
    • care plan goals are patient-centric
    • there is regular review and proactive patient follow up, and
    • there is active case management of patients at risk of decline or with low health literacy.

Over 50% of hospitalisations in Australia remain preventable – this is costly for our health system, and distressing and inconvenient for patients. A 2017 analysis from the Australian Commission on Safety and Quality in Health Care shows that COPD, diabetes complications and asthma are the top three conditions for which hospitalisations could have been avoided through better community-based treatment and management.

There is increased risk of avoidable hospitalisation associated with rurality, age, socioeconomic status and First Nations status.

Let us look at diabetes as an example. The annual direct cost of care for people with diabetes without complications is $3,500 per annum. This increases to $9,600 when complications arise, with the full economic cost due to lost productivity, absence from work, early retirement and premature death being eight times higher than that (Australian National Diabetes Strategy 2016-20).

  • In an economic study we undertook for a rural Victorian health service, we found that once a person has poor control of diabetes mellitus and is hospitalised in an acute setting, the cost to the health system for inpatient care for common admission reasons range from $820 to $4,302 per separation depending on the reason for admission; while the average primary care cost for best practice diabetes care was only $1,861 per annum (incorporating counselling, dietetics, nursing, exercise physiology, physiotherapy, podiatry, occupational therapy, health coaching and general practice care).
  • The further patients lived from urban and rural centres, the more difficulty they had accessing allied health care.

Because we spend so much money and time treating the complications associated with suboptimal treatment of chronic illness, we have less funds to assist Australians to reduce risk factors for developing chronic disease: an astonishing 38% of the burden of disease in Australia remains avoidable, with the leading causes being tobacco use (8.6% avoidable disease burden), weight (8.4%), diet (5.4%), high blood pressure (5.1%) and alcohol use (4.8%).

These findings highlight the need to keep reconsidering how to support people with chronic conditions and complex care needs, and commissioning is a key opportunity. The next version of patient-centred medical homes is exciting, but we are a long way from agreeing on effective models there. 

At Larter, we have been privileged to work with Primary Health Networks (PHNs) to continuously improve health program commissioning strategies by assessing local needs, reviewing existing contracts and consulting with service providers and consumers. This includes using consumer and lived experience views to inform our thinking. 

Consumer and health professional perspectives: GP-led chronic disease management (CDM)

From a consumer perspective, issues with CDM care planning we’ve identified at Larter include:

  • Lack of understanding of GP chronic disease care plans – such as confusion over who develops them, and their purpose
  • Poor care coordination following ‘signing off’ a care plan, including difficulties finding services
  • Access issues related to personal mobility, transport, service availability and cost
  • Consumer concern about the time management plans take and worries GPs do not have the time (lessened if led by skilled general practice nurses)
  • Lack of promotion of services
  • Beliefs there are ‘power plays’ and disconnection between care teams.

When working with health and local council stakeholders, we have identified the following systemic concerns:

  • Limited GP knowledge of the evidence base that supports effective CDM care plans, with many believing they are only a means to MBS allied health, or to practice viability
  • Inadequate marketing of funded prevention programs that could be incorporated into care plans
  • General practice nurses lacking an office space, access to patient records, knowledge or skills to play a lead role in CDM care planning
  • The need to enhance patient health literacy – finding ways to help adults understand the importance of prevention, mindful of the needs of different population cohorts (e.g. culturally diverse, those lacking access to internet or transport)
  • A need for more care coordination.

Additionally, primary care workforce issues, particularly in rural and regional areas, can leave health systems struggling to meet demand for acute care let alone planned primary care.

Aligning programs with the National Framework

CDM commissioning strategies may benefit from stronger alignment with the COAG National Strategic Framework for Chronic Conditions (2017). The Framework moves away from a disease-specific approach and encourages the health system to address shared risk factors, social determinants of health and multi-morbidities across a range of chronic conditions.

Our desktop analysis found that many programs don’t address all of the Framework’s components, in particular having an inadequate focus on prevention and tailored care for vulnerable populations.

Larter’s work with PHNs

Our experienced consulting team can work with PHNs to facilitate the delivery of high-quality, effective initiatives to achieve better outcomes for people with chronic disease.

Larter can support PHNs to:

  • Reconceptualise chronic disease programs to align them with the National Strategic Framework for Chronic Conditions: Prevention, Care and Priority Populations
  • Identify duplication between currently funded programs and services already available within the local community
  • Identify service gaps and discuss referral pathways and potential partnership opportunities
  • Discover cost-effective ways to enhance access to services and health promotion messaging by leveraging other regional and state-wide programs through marketing and/or partnership opportunities
  • Evaluate commissioned initiatives, or whole CDM programs.

Contact us to discuss your needs for a program review or commissioning strategy support.


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