Integrated Chronic Disease Management

About Integrated Chronic Disease Management (ICDM)

Integrated Chronic Disease Management is the provision of person-centred care in which health services work with each other and with the client (and/or their carer) with a chronic illness to ensure coordination, consistency and continuity of care for clients over time and through the different stages of their condition.

The Primary Health Branch of the Department of Human Services has endorsed the Wagner Model for Improving Chronic Care as the model to inform and guide service system redesign required to support people with chronic disease. The Wagner model provides a framework that helps identify the systems changes (within primary health care services and across the service system) that are necessary to improve the coordination of care for people with chronic disease. Taking a systems approach is important to ensure the delivery of proactive and integrated client centred care.

The model has six interdependent elements for improving chronic care which include:


Communityresources and activities that provide ongoing support for people with chronic disease/s.
Health systemssupport prepared and proactive practice teams.
Self-management supportempowers and prepares clients to manage their health and health care.
Delivery system designassist care teams to deliver systematic, effective, efficient clinical care and self-management support.
Decision supportincluding design, systems and tools to ensure clinical care is consistent with evidence-based guidelines.
Clinical information systemsincluding data systems that provide information about the client population, reminders for review and recall, and monitor the performance of care teams.


Integrated Chronic Disease Management in Campaspe

Campaspe PCP has implemented a number of initiatives to date including: