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Campaspe PCP Chronic Disease Management Introduction Campaspe Primary Care Partnership.

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Presentation on theme: "Campaspe PCP Chronic Disease Management Introduction Campaspe Primary Care Partnership."— Presentation transcript:

1 Campaspe PCP Chronic Disease Management Introduction Campaspe Primary Care Partnership

2 Objectives To introduce the principles of ICDM To increase understanding of goal setting and where it fits the consumer self management To introduce opportunities for workforce capacity building

3 Integrated Chronic Disease Management - Principles Person centred care Consumers active partners Increasing choice and control Providing right care in the right place at the right time Proactively promoting health

4 Chronic Disease Self Management CDSM support o Philosophy or approach to working with people o Not any one specific intervention

5 Definitions Chronic disease o Long term (remainder of consumers life) o No cure Self management o Living with ongoing chronic disease – consumer management

6 Management hours 8,766 hours

7 Behavioural Goal Setting Identified/ agreed issues Gradual process Making small sustainable changes

8 Goal Setting Linked to problem/issue Written in positive Written in the consumers words SMART Can be maintenance goals Should not be interventions

9 Setting Goals and Action Planning Something the consumer wants to do Achievable Action specific Answer what, how much, when, how often? Confidence level 7 or more

10 Goal setting – practice example Overall aim to lose weight Goal Specific- aim to help lose weight by increasing the amount of walking Measurable- walk for 30 minutes Achievable- confident that could manage to walk for that long Realistic- need to take the dog for a walk so will be the motivation I need Timely- will walk 3 times per week in the afternoon

11 What is Care Planning? Dynamic process Involves negotiation, decision making and goal setting Relies on good communication between consumer, service providers and GPs

12 Benefits of Care Planning Assist consumers to set goals Encourages consumer involvement and self- management Manages and monitors long term care Provides a checklist Documents information e.g. action plans Encourages team approaches Is proactive rather than reactive Increase consumer awareness of services

13 Person-Centred Practice Principles Partnership approach Holistic Open communication Respect and privacy Inclusive of family and carers Supports self-management and responsibility Participation in decision making Supports autonomy

14 Communication Communication skills Interviewing open ended questions allow consumer to express issues Active listening what the consumer is actually saying

15 Workforce Development Courses available Better Health Self Management Motivational interviewing Flinders model Health Coaching

16 Active Service Model HACC initiative People to live independently autonomously

17 Work force development Online CDSM learning package o Heart Research Centre Motivational interviewing CD o Heart Foundation Service Coordination self paced training module CD o PCP

18 Consumer Courses Recognised programs for consumers Better Health Self-Management Diabetes prevention programs LIFE RESET Cardiac rehabilitation

19 Conclusion Role of health professional is to enable the consumer to develop the individual skills they require to manage their own health

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