Integrated Chronic Disease Management

Advance care planning
The Department of Health and Human Services website offers a range of resources to assist both consumers and professionals with Advance care planning. The site provides an overview of why advance care planning is important, offers best practice information, details legislation and offers tips for initiating and implementing advance care planning.

ADMA Integrated Care Model
Together with a range of partners, The Australian Disease Managment Association (ADMA) have developed the Victorian Integrated Care Model (VICM). The Model aims to improve the experiences of care and outcomes for patients with complex and chronic conditions through increased collaboration by health care providers at the local level.

ADMA Integrated Care Tools
The Australian Disease Management Association (ADMA) have collated a range of tools and resources which may be useful to those working in the area of service integration. Categories of tools include; assessment, diseases, evaluation tools, guidelines, health literacy, pathways, education material and more.

Integrated Care Communities of Practice (CoP) Toolkit
The Australian Disease Management Association (ADMA) has coordinated the development of Integrated Care Communities of Practice (CoPs) in the South East Melbourne Region under the Victorian Department of Health and Human Services (DHHS) Victorian Integrated Care Model. In addition to developing the CoPs, a toolkit has been established to aid those who wish to strengthen their own CoP.

Integrated care in Victoria 
Integrated care is the provision of well-connected, effective and efficient care that takes account of and is organised around a person's health and social needs. Integrated care is especially important for more effective management of chronic diseases and for people with complex needs. A range of resources related to integrated care of chronic disease can be accessed from this page.

Wagner Chronic Care Model
The Wagner Chronic Care model is an evidenced based framework for chronic illness. This framework has been endorsed by the Victorian Department of Health and Human Services Primary Care Branch.

The Wagner Chronic Care Model identifies 6 essential elements for improving chronic care:

  1. Community resources
  2. Organisation of healthcare systems
  3. Self-management support
  4. Decision support
  5. Delivery system design
  6. Clinical information systems

The model is built on the premise that these six elements work together to create productive interactions between an informed, activated patient and a prepared, proactive practice team – which is what leads to improvements in outcomes.


Service Coordination

Service Coordination Practice Resources
The Department of Health and Human Services provide links to a number of useful Service Coordination Practice resources including the Victorian Service Coordination Practice Manual, Good Practice Guide, Continous Improvement Framework and information on Privacy and Consent and Care Planning.

Service Coordination Tool Templates (SCTT)
SCTT is a suite of templates developed to facilitate Service Coordination Practice.

Service Coordination Online Learning Module
This e-learning tool supports the use of SCTT. Organisations are encouraged to include this module in their staff orientation. Experienced SCTT users may use this to refresh their knowledge and keep updated with recent changes.

Service Coordination Continuous Improvement Framework
This tool is designed to assist agencies in implementing, monitoring and continuously improving service coordination.



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