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summary
Background
The health care challenge of this century
There is a rapid worldwide increase in the number of people whose lives are affected by a chronic condition. These conditions are now estimated to account for more than 60% of all deaths and are impacting significantly on health systems worldwide. To be able to cope in the future, health systems need to plan changes to their organisation and structure.
What is a chronic condition?
Chronic conditions are defined as disorders or diseases that require ongoing medical care, including monitoring, treatment, and coordination among multiple providers; they limit what people can do, and are likely to last longer than one year.
They include but are not limited to:
- Cancer
- Ischaemic heart disease
- Stroke
- Diabetes
- Chronic respiratory disease
- Depression
People with one or more chronic conditions often suffer periods of sickness and have a decreased ability to live their lives to the full.
The causes: Many chronic conditions share common risk factors such as tobacco smoking, poor diet, psychosocial stress, obesity, alcohol and other substance misuse and physical inactivity.
Who gets sick? In New Zealand Māori, people with lower socio-economic status and Pacific Islanders are disproportionately affected, and die earlier than other population groups. In Nelson Marlborough cardiovascular disease and diabetes predominate.
Who can help? International evidence shows that access to effective Primary Health Care services is the main factor in successful chronic condition management, and that this sector should lead the way in chronic condition development and management.
The bigger picture: The Minister of Health has identified the need to control the burgeoning chronic disease burden as a priority. It is seen as a major risk for the viability and sustainability of the health system that will increase as the population ages and as technology advances.
This Chronic Conditions Framework is informed by NMDHB principles as well as those of the 2007 National Health Committee report ‘Meeting the needs of people with chronic conditions’.
The challenge: The impact of chronic need will be of such a magnitude that health services as they are currently organised and structured will not be able to respond appropriately. Nelson Marlborough District Health Board is already increasingly challenged by the need for health care and disability support services.
What’s happening now?
The DHB has programmes in place that include health promotion, cancer screening, cardiac and respiratory rehabilitation, disability support, needs assessment and palliative care. However, not everyone in Nelson Marlborough has access to these services, they often operate in isolation, they are under-resourced and not organised for managing chronic conditions.
The Solution
The NMDHB Chronic Conditions Framework offers a systematic approach to managing chronic conditions now and into the future.
It is in three parts:
- the framework model describing a whole systems approach
- an outline of ‘packaged interventions’
- and an implementation action plan.
The Chronic Conditions Framework will bring about the broad systems change necessary to improve care. These changes include:
- Improved packaging of accessible services across all levels of need
- The development and involvement of competent multidisciplinary teams
- Working to better engage patients and clients to improve adherence to care
- Connected information systems for continuity of care between health care providers
- More collaboration/cooperation across organisations to achieve seamless care.
- The introducution of new or redesigned services
- Addition of care options including complementary and traditional cultural care practices
- Development of new tools and skills to support improved clinical care
- Innovative approaches to funding and resourcing services.
Connections
The Chronic Conditions Framework connects with other Nelson Marlborough DHB priority action areas including the District Wide Clinical Services Plan, Health of Older People Continuum of Care Services and capital developments such as the Wairau Hospital redevelopment.
Intervention Packages for Chronic Condition Management
The proposal is for five progressively more intense levels of care that include both patient self-management and care plans developed by the clinician and patient.
1. Preventing chronic conditions - a collaborative community development approach with information, education, and resources to enable individuals and communities to develope sustainable health and healthcare.
2. Management of precursor chronic conditions - targeted awareness-raising for people with early or mild symptoms aimed at changing behaviour and helping individuals and families with self-management skills.
3. Early chronic condition management - provided by primary healthcare providers to ensure continuity and care management for people with early conditions; includes condition specific approaches such as annual recall programmes.
4. Advanced chronic condition management - a generalist/specialist care package for people with more advanced complex chronic conditions who require more intense levels of healthcare and disability support care.
5. End stage chronic condition management, palliative care and support - support for the person and their family/whanau/caregivers, including bereavement care - aiming to improve overall quality of life for all concerned.
documents
The NMDHB has developed a Chronic Conditions Framework, which will provide a systematic approach for our population to prevent and manage these conditions. The Chronic Condition Framework consists of three parts
- NMDHB Chronic Conditions Framework
"Maximising outcomes for people with chronic conditions". The Framework provides the foundation for a systematic “whole of health sector” (whole systems working) approach to the planning and delivery of services for Nelson Marlborough people with chronic conditions. The Framework outlines approaches to chronic condition management across the continuum of care from health promotion, illness/injury prevention and the clinical and self-management of chronic conditions.
- An outline of packaged interventions
This document is currently still in draft format. The ‘intervention packages’ under the NMDHB Chronic Conditions Framework are structured around each of the populations of need across the continuum of care activities (general population to palliative and supportive care) and detail the essential organisational components necessary to successfully manage chronic conditions (self management, delivery systems, decision support, and clinical information) <<interventions package May 08.pdf
- And an implementation action plan.
This document is currently under development.
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