Primary Health Care Reform in Australia - Report to Support Australia’s First National Primary Health Care Strategy

Element 4: Well-integrated, coordinated, and providing continuity of care, particularly for those with multiple, ongoing, and complex conditions

Objective: All Australians, particularly those with multiple, ongoing and complex conditions, experience primary health care services which are coordinated across multiple care providers, with transitions across health sectors actively managed and continuity of care supported.

Key Points

The prevalence of chronic disease is placing an increasing burden on patients and their carers, and on the whole Australian health system and its service providers. For patients, especially those with multiple chronic diseases, lack of service coordination and assistance in transitioning between health services and sectors can lead to poor continuity of care, resulting in potentially avoidable negative health outcomes such as hospitalisation.

It has been suggested that a ‘medical home’ for patients, complemented by voluntary patient enrolment, can allow for better population health planning as well as strengthen integration, coordination, management and continuity of care for patients.

To some extent, introduced MBS items have been effective in improving coordination and continuity of care for Australians with chronic diseases by providing care plans and access to allied health professionals. Nevertheless, there is an ongoing need to reduce the complexity of these items, and to improve the education of GPs about the use of items and how to provide quality chronic disease care. Reviewing and improving education opportunities for GPs and decision making systems may better enable GPs to provide optimal care for patients.

It has also been suggested that the different business arrangements and funding models under which different health services operate impact on communication pathways between health services and consequently on a patient’s transition across health sectors. One level of government assuming responsibility for all of primary health care has been suggested as one way to drive better service integration in this space.

Regardless of funding responsibilities, a viable proposal is to increase the number of integrated care models which would allow patients to access a range of closely located specialist, nursing, GP and allied health professionals in one location. Further, such models may enable patients to become more involved in self-management of their health condition and improve their health literacy.

Due to the widespread nature of chronic disease in Australia, changes to its management need to involve development of care models based on the best Australian and international examples, that are evidence-based, targeted for different populations, and involve service delivery system design and greater health professional and patient education.

For all health consumers, but especially those with multiple chronic conditions and complex care needs, their interactions with the health system need to be well integrated with effective and coordinated transitions between different health services and health providers and continuity of care.

The priority issues identified through the Discussion Paper, and confirmed through stakeholder feedback, are the need to:
  • improve integration, coordination of and accountability for care, particularly for those with complex care needs;
  • improve the targeting and quality of care provided to patients with complex care needs; and
  • improve access to available workforce to better support integration of care.
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Where are we now?

The growing burden of chronic disease is one of the major challenges facing health systems across the world, as noted in Chapter 2. For those living with chronic disease, it can affect nearly every aspect of their life. Over time, it can reduce their participation in work and other activities, and place increasing burdens on their families and carers. Chronic disease is also associated with anxiety and depression.

When well-managed, the health impacts of chronic disease are reduced, progression of disease is delayed, quality of life is improved, there is a positive impact on carers, workforce participation is maintained or increased, and downstream expenditure on health services can be reduced.

In contrast, when disease is poorly managed, it will almost always be associated in time with more complications, acute exacerbations and unplanned and avoidable hospitalisations.

In Australia, the different business arrangements and funding models under which services operate impact on communication pathways between health services and can confuse or dilute responsibility and accountability for individual patient care and service delivery, for example, between Commonwealth subsidised and state/territory government services. They can also reduce flexibility and adaptability at the service delivery end as well as contribute to higher administration costs and increased risk of errors at handover of care.

Individuals, their families and carers can experience increasing frustration and difficulties navigating their way unassisted to access health care from different providers and across different care settings, each operating under different arrangements and with different costs. Health professionals can be unaware of the range of local services that their patients can access or the basis on which they can access them, which can severely restrict the design and implementation of multi-disciplinary care plans or treatment options. Private providers, particularly GPs, also express frustration about the difficulties in obtaining access for their patients to state-funded services.

The National Chronic Disease Strategy (NCDS) endorsed by Health Ministers in 2005 provided national direction for improving chronic disease prevention and care. The NCDS included a strong focus on improving the integration and coordination of care for those Australians with, or at risk of developing, chronic disease. While there has been investment across all levels of government (including through COAG) in a range of initiatives to improve chronic disease management, and by health insurers, evidence suggests that chronic disease in Australia can be poorly managed and highly variable, particularly for disadvantaged sub-population groups.
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Potentially preventable hospital admissions

Poor management of chronic disease shows itself through potentially preventable hospital admissions.185186 Potentially preventable hospitalisations are those conditions where hospitalisation is thought to have been avoidable if timely and adequate non-hospital care had been provided. Importantly, as discussed under Element 2, individual behaviour can be an important determinant of health outcomes for individuals with chronic disease, for example, through adherence to treatment regimes or aspects of lifestyle.

The importance of these issues to the effective operation of the entire health system has been recognised in the National Healthcare Agreement (NHA) which has identified a reduction in potentially preventable hospital admissions as a performance benchmark for primary health care.

The AIHW reported that 731,000 hospital separations in 2007-08 (9.3% of all separations) were potentially avoidable, a rate of 33 per 1,000 people. The majority of potentially preventable hospitalisations, 58%, were related to chronic conditions such as diabetes and asthma, with 40% relating to acute conditions (eg appendicitis) and 2% to vaccine-preventable conditions (eg measles).

The rate of potentially preventable hospitalisations was higher in lower socioeconomic areas (42 per 1,000) than in higher socioeconomic areas (25 per 1,000), and was also higher in remote areas (74 per 1,000) than in major cities (30 per 1,000). Figure 8 shows the major potentially preventable hospitalisations related to chronic conditions by type of condition – diabetes complications account for 52% of potentially preventable hospitalisation chronic conditions.187

Figure 8: Potentially preventable hospitalisations for chronic conditions, 2007-08.

Figure 8: Potentially preventable hospitalisations for chronic conditions, 2007-08.

Source: AIHW, Australian hospital statistics, 2007-08
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The concepts of ‘medical home’ and ‘patient enrolment’

In terms of integrated and coordinated care, the concept of a ‘medical home’ or regular provider is increasingly recognised internationally as an important component of improving health care. The Commonwealth Fund 2007 survey found that 96% of Australian adults surveyed have a regular doctor or place of care (or a ‘medical home’).188 The Survey reported that for those Australians with a medical home, defined as having a ‘regular provider who knows you, is easy to contact and who coordinates your care’, 87% rated the care they received as ‘excellent’ or ‘very good’ compared with only 60% of those who do not have a ‘medical home’.189 It also found that Australian adults who have a regular provider were significantly more likely to have a written care plan, receive reminders for preventive/follow-up care, experience less medical errors and report that they receive excellent or very good care from their doctor.190

This survey-based measure of ‘loyalty’ or continuity of care is higher than relevant figures derived from Medicare data. From Medicare data, of the individuals who had more than one in-surgery consult, 47.8% (6.5 million) had all of their surgery consults with a single provider or in a single practice. The rate climbs to 84% if patients who visited only two practices or two providers are classified as ‘loyal’ but then declined as the number of surgery consultations for a patient increased: dropping below 50% by four surgery consultations, about 33% by 12 consultations and under 20% by 50 consultations.

Both the survey and MBS data suggest that a high proportion of Australians have either one or two ‘home’ providers of primary (medical) care; whether these correspond to the concept of a ‘medical home’ (eg in terms of a place that coordinates the patient’s care) is less clear.

While the ‘medical home’ concept can bring potential benefits to the whole population, it is particularly applicable in the management of chronic disease. In international experience, the ‘medical home’ is also coupled with some form of voluntary or compulsory patient enrolment. Internationally, enrolment for particular health conditions or populations is being used as a mechanism for improving the continuity, coordination and integration of care.

Establishing an ongoing relationship with a health service through enrolment or registration has potential advantages in terms of continuity of care. It can encompass oversight and coordination of care for an individual patient including responsibility for maintaining information about that individual and active engagement in transitions between care settings.

A voluntary registration arrangement is included as a component of the recently announced COAG Indigenous National Partnership. This arrangement does not limit an individual’s access to services from other providers but actively encourages an ongoing relationship between the practice and the patient.
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The use of MBS chronic disease management items

Within the MBS, Chronic Disease Management (CDM) items were introduced in July 2005 to help improve coordination and continuity of care for Australians with chronic diseases. The introduction of these Medicare items which replaced the original Enhanced Primary Care (EPC) case planning items first introduced in 1999, acknowledged the value of multi-disciplinary care planning. From November 2004, these items have also served as a gateway to a range of allied health services which are rebated through the MBS for patients with chronic conditions and complex needs. In 2007-08, 1.322 million allied health services were claimed with $63 million MBS benefits paid at an average of $48 per item claimed.

Since the introduction of these items, care planning activity has increased compared to the original EPC multi-disciplinary care plan items. There has been a significant increase in the number of individuals receiving care planning services (now comprising both GP and team care) subsidised through these items and in the number of providers using (at least one of) the items. In 2007-08, 2.064 million GP CDM items were claimed with $203.8 million MBS benefits paid at an average $99 per MBS service claimed.

The impact of the CDM items is, however, open to question. As Table 8 shows, coverage of the eligible population would seem to be uneven, given as usage is concentrated on a small number of GPs. Table 8 provides a measure of concentration for selected GP MBS items based on data from 20,600 GPs who claimed more than 1,000 services in 2006-07. It shows that while most doctors use some of the items, a small number of doctors make most of the claims. For example, while 86% of those GPs who claim more than 1,000 services a year use the care plan items, only 34% claimed them more than 50 times a year and the 10% of GPs who claimed most care plans accounted for 54% of all care plans claimed.

Table 8: GPs claiming new MBS items, 2006-07

Care Plans

Health Assessments

Mental Health

Aged Care

After Hours

Make at least 1 claim86%69%83%58%71%
Make more than 50 claims34%13%14%26%37%
% claimed by top 10% of GPs54%41%50%63%59%
% of GPs where these items make up at least 5% of their total claims8.0%0.3%1.5%16.8%24.8%
Source: Medicare data
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A recent review of the MBS care planning items noted the need for greater education of GPs in the appropriate use of those items. A Medicare Australia audit which fed into that review found that only 64% of items claimed were compliant with MBS requirements.

There are also concerns that the quality of care provided is unknown and that the objectives of coordination and continuity of care may not be being achieved. Over 2005-07, only around 30% of patients with a GP Management Plan received an MBS review item and only 20% of patients with a Team Care Arrangement received an MBS review item.

Correspondence to the Department of Health and Ageing from the Professional Services Review (PSR) has highlighted the risk of these higher rebated items being accessed more for business than clinical considerations. In particular, the PSR is concerned that plans are being opportunistically generated, based on system driven templates, that do not reflect the patient’s actual needs and that are not necessarily shared with or even provided to the patient. Concerns have also been expressed that care plans are being provided to individuals whose clinical condition could readily be managed by ‘normal care’ and that while a benefit is payable for the preparation of a care plan, there is no requirement that the plan is actually delivered or is even capable of being delivered. The PSR raised these issues in their 2005-06 Annual Report.191

In summary, the CDM items have been criticised in relation to complexity and ‘red tape’/paperwork, time constraints, eligibility requirements, overlap and duplication, and lack of understanding, support and remuneration for the roles of other team members within the multi-disciplinary team. The EPC items, and current MBS funding arrangements for primary health care more generally, have also been seen by some as contributing to fragmentation of primary health care with the number and complexity of separate items being a cause for confusion amongst health professionals and patients.
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Improving the quality of care for people with chronic disease in general practice

Other than specific issues with the CDM items, evidence suggests that about half of general practice care for chronic illness, in general, does not meet optimal standards.192 This has been demonstrated in the care of children with asthma and adults with type 2 diabetes or hypertension.193 Factors contributing to the gap between optimal and current practice include the method of financing, the availability of other disciplines to participate in team care, limited engagement with self-management education, and lack of information and decision support systems.194

Access to health professionals is discussed under Element 1. However, access to a multi-disciplinary health care team is also key to chronic disease management. Multi-disciplinary team care has been shown to have positive effects on both provider behaviour and some patient outcomes, particularly for diabetes, hypertension and lipid disorders.195 However, a 2006 survey indicated Australian GPs were less likely than primary health care doctors in the UK, Netherlands, Germany or NZ to use a multi-disciplinary team approach to the management of chronic conditions’.196

Chronically ill patients are most likely to suffer the consequences of poor care coordination and transition between care settings.197 This is because they are required to have multiple contacts with the health care system and often see a range of specialists and primary health care professionals to manage their more complex needs in the course of an acute episode of care.198 Significant care coordination problems (with high potential for errors and adverse events) are also experienced when individuals transition across health sectors or stages of care provision (for example: from inpatient to ambulatory care; or acute to long-term care, including residents of aged care services).199

In response to these issues, there are a growing number of integrated models of care whereby patients with chronic disease receive a suite of specialist, GP, nursing and allied health services in the community setting, close to where they live. For example, the Chronic Obstructive Pulmonary Disease (COPD) Community Linkage Service in Perth, Western Australia, offers community-based care for people with a primary diagnosis of COPD via a respiratory specialist, community nurse, and physiotherapist, who work in conjunction with the patient’s GP. The service essentially provides a 'one-stop' shop in the community that includes specialist assessment and review, access to spirometry, pulmonary rehabilitation, self-management education and social support for patients with COPD.

Building on the Coordinated Care Trials, which demonstrated both improved health outcomes and reduced costs of care,200 there have also been a number of examples of explicit funding of care coordination support for individuals with chronic and complex care conditions, including work by GP Partners for the Queensland Government and Medibank Private, and work undertaken by McKesson, for the Department of Veterans’ Affairs (DVA).
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What the submissions said

There was general recognition that some target groups needed assistance in navigating the system and accessing services, with a role for care coordination.

The key target groups that would benefit from a more coordinated approach to their care are those with complex chronic disease and the frail elderly. … We believe practice nurses could take on a liaison role for general practice clients requiring care coordination or assistance with navigating the health care system.201Some stakeholders saw GPs and the general practice as the most appropriate location for coordinating the care of individuals with multiple, ongoing and chronic conditions.

The Australian primary health care system should be based around patients’ health care needs, enabling patients to receive timely and appropriate coordination of their care. In order for this to occur, the system requires support for general practitioners to coordinate the care of their patients, particularly the care of patients with multiple, ongoing and complex conditions… General practitioners should be recognised and funded for their integral role in coordinating and supporting patients when implementing patient centred strategies.202The general practice team is central to care coordination and ongoing holistic care. Referral from the GP should remain the entryway to specialist care.203The coordination of care is best managed in the general practice environment …. It essential that the [care coordination] role be performed within the practice so that established relationships and communication mechanisms can be best leveraged.204The capacity of practice nurses and nurse practitioners to provide a range of functions, including care coordination, was emphasised in some submissions.

Practice nurses are critical in ensuring general practice delivers well-integrated and coordinated care in a way that promotes continuity of care. A growing role for nurses in primary health care, which makes full use of their existing nursing skills, is that of working with patients with multiple, ongoing and complex conditions. Everyday practice nurses see patients who are in great need of support in navigating our complex health and social services system…This is a role which fully uses the wholistic approach of the professional nurse in clinical and service coordination and we would support a clearly autonomous role for nurses in this capacity within the general practice team…Non-clinical service coordination models which sit outside the practice do not seem to take advantage of the health professionals within the practice working together to provide a coherent service and plan of care for the patient.205The changing population needs mean that not every patient needs a medical specialist to manage their care, and nurse practitioners are recognised as effective in the integration and coordination of care across all aspects of the health sector, particularly between primary care and hospital services.206A number of submissions included suggestions for ways in which to ensure better continuity of care across a number of different care settings, including use of universal processes and eHealth solutions.

Transition points in care are a high risk area for preventable adverse medicines events. Universal processes are needed to ensure accurate communication of information about the consumer’s medication history to all health professionals involved in his/her care. This will require a systems approach across the entire medication management pathway and in all sectors of the health system.207E-Health and the Individual Electronic Health Record (IEHR) have the potential to improve continuity of care and health literacy, to provide useful prompts for different interventions such as a medication review or prevention education, and to provide information and educational resources and tools at the point of consultation and/or decision-making.208Some submissions described a model and function for coordination with implications for how the function could be designed.

The objective of this revised primary health care system is to increase access for people requiring timely and targeted evidence-based interventions especially to address chronic disease and other health issues by enabling self-referral and referral via a triage type system to allied health providers. This system could be provided by a range of health professionals. Under this model the GP remains at the core of the consumers’ primary health care treatment with this role being maintained via communications systems rather than referral pathways.209The importance of matching care coordination services to the target population and to their specific needs, for example, in relation to the Indigenous population, was identified.

…using the expertise of Aboriginal community controlled health services through coordinator positions established within NACCHO [National Aboriginal Community Controlled Health Organisation] Affiliates…ACCHSs [Aboriginal Community Controlled Health Services] are best placed to coordinate local and regional service provision to Aboriginal peoples.210

Box 2: Overview – response to selected Discussion Paper questions

Question: Would there be advantages in patients having the opportunity to ‘enrol’ with a key provider? (p.24, Discussion Paper)
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61 submissions addressed this issue - of these 82% were generally in favour of voluntary patient enrolment. Enrolment was recommended particularly for patients with chronic/complex disease and young families, but it was noted that enrolment should be voluntary and flexible. It was also suggested that an electronic health record would have similar benefits. The benefits of voluntary enrolment mentioned by submissions included continuity of care, better coordination, and greater patient participation. The problems with voluntary enrolment identified by submissions included lack of choice, favouring of urban areas, and the lack of inclusion of disadvantaged populations.

There was a general view that patient enrolment offers a number of potentially significant benefits for individual patients, communities, service providers and funders. Advantages to patients include clarification of expectations and greater coordination of care.

Voluntary enrolment for patients with specific chronic disease prevention and management needs in a single practice offers the potential to encourage a more proactive and coordinated approach to patient management by reducing fragmentation and duplication of service provision…211At the level of individual patients, the most basic advantage would be to clarify the mutual responsibilities and expectations of providers and patients, and in the Australian context remove the fear that active follow up would be seen to [be] soliciting for business. This could provide a basis for the development of more actively coordinated systems of care, ranging from better follow up and reminder systems to the redesign of models of care, particularly if enrolment were accompanied by some form of capitation payment that created a predictable flow of funds.212Many submissions pointed to the potential of voluntary patient enrolment to enable more systematic approaches to preventive care.

Patient enrolment would also allow effective monitoring and evaluation of preventative health initiatives for national reporting. Registers of patients within a practice with particular risk factors or chronic conditions which are the target of population based preventative health programs would identify the target groups for implementation of appropriate interventions.213It was pointed out that individuals are already enrolled with practices to some extent, particularly in rural areas.

However, support for patient enrolment was by no means unanimous with many stakeholders highlighting the importance of choice and several submissions emphasising the role of eHealth as a means to improve coordination of care.

The freedom of patients to choose their doctor and for doctors to choose not to treat particular patients is paramount.214Given that one of the key objectives to developing a primary health care strategy is making the patient the centre of decision making, there is merit in a system where consumers have the ability to decide which health practitioner they access rather than being tied to any one key provider. Effective sharing of information via safe and secure eHealth networks has the potential to overcome any information gaps in a patient’s health history rather than insisting a patient enrol with a key provider.215The Consumers Health Forum, in particular, was opposed to the proposal.

Consumers do not want to register or ‘enrol’ with a particular coordinator or managed care team as such arrangements can limit access and choice, for example, in relation to consumers seeking a second opinion. Such a system also fails to recognise or cater for those with transient lifestyles or personal circumstances that make enrolment impractical or impossible. … such as the homeless, Indigenous populations, those with mental health issues and those with limited incomes.216

What is the way forward?

International work identifies key elements of an effective chronic disease management model. This model includes an efficient delivery system design; evidence-based and patient-centred decision support; clinical information systems to facilitate efficient and effective care; self-management support through patient empowerment; and mobilising community resources to meet patient needs.217 Effective chronic disease management is also greatly facilitated through readily accessible, accurate and up-to-date patient information (for example, through an Individual Electronic Health Record).

There is also a growing body of literature around chronic disease management interventions and their effectiveness. While current evidence is inconclusive, there is increasing understanding and acceptance of the broad features required for interventions to improve chronic disease management. In particular, there is growing consensus of the need for stratification or grouping of individuals based on complexity of disease, needs and capacity to self-manage, and the broad nature of interventions appropriate for different categories.

This approach divides the population into four groups or risk categories in relation to chronic conditions (Figure 9). People in each of these risk categories require a different response from the health system.
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Figure 9: Chronic disease risk distribution

Figure 9: Chronic disease risk distribution

The Kaiser Permanente approach to chronic disease care218 estimates that of the group of at-risk individuals approximately 3-5% of patients with chronic conditions require case management, 15-27% require care management, and 70-80% can be managed with supported self-care (corresponding to the very high, high and lower risk categories in Figure 9).219

The percentage of the Australian population covered by these categories cannot be quantified in exact terms given variations in applying criteria based on need and risk. However, estimates based on multiple hospital admissions or on prevalence of major chronic diseases suggest that in broad terms around 10-16% of the Australian population could be covered by the top three levels of the pyramid (ie very high, high and lower risk). For a well population, primary prevention is promotion of healthy behaviours and environments across the life course, and universal and targeted approaches. For the at-risk population, secondary prevention and early detection are vital. This includes screening, case finding, periodic health examinations, early intervention, and control of risk factors such as lifestyle and medication. For populations with established disease, treatment and complications management (including acute care) may be required. For populations with controlled chronic disease, continuing care, maintenance and rehabilitation may be required. Self-management and support for patients’ capacity to self-manage are relevant to different degrees across all levels.
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As part of an effective chronic disease management model for individuals with established disease, optimal uptake of care planning requires:
  • clarification, definition of, and appropriate funding for, the roles of different
    multi-disciplinary team members;
  • changing patterns of interactions between care providers;
  • an understanding of local services and supports;
  • alignment of roles and work practices (including active and structured facilitation of teamwork);
  • changes to organisational arrangements, especially for those under the care of specialists;
  • clarification of the patient’s role in care; and
  • training for individuals, their families and carers as well as health professionals in
    team-based care.220
Collectively, these factors can work together to support increased collaboration and integration between providers and streamline transitions of care. At the same time however, there is increasing recognition of the importance of reducing avoidable hospital admissions and ensuring that individuals are receiving health care services closer to home. Integrated chronic disease management models provide the opportunity for GPs, supported by specialists and other health professionals, to manage complex and chronic diseases in the community setting. Such models also offer the potential to improve access to specialist medical care closer to people’s homes, strengthen the interface between GPs and specialists, and to build capacity within general practice through the provision of mentoring, support and education on best practice management of specific diseases (eg CVD, COPD or diabetes). Clearly this is an important priority for consideration under the Draft Strategy.

In relation to the current operation of the MBS arrangements, there is potential for improving chronic disease management, through options such as:
  • better targeting services to needs;
  • encouraging more ongoing care through review activity;
  • providing greater flexibility for multi-disciplinary teams and allied health services; and
  • supporting quality improvement through promotion, awareness and clinician education activities.
Further developments in eHealth will also be significant to improving coordination of care for those with chronic disease. The OECD has identified that better integration of care across health sectors and care modalities can be supported by enhanced information transfer across providers and payment models which encourage cooperation across sectors and reward multi-disciplinary care.221

Effective communication including timely transfer of information between providers and across health settings is integral to the provision of effective team-based care, particularly in referral and collaboration. Technology solutions supporting efficient monitoring and follow-up of patients have potential to support prevention approaches and individualised care coordination. Research indicates that countries with better information flow report higher rates of referral from hospitals back to primary care and improved coordination in the provision of longer-term multi-disciplinary care.222
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In the Australian context the experience of patients with chronic disease can be further complicated by both Commonwealth and state/territory governments having responsibility for aspects of primary health care and state/territory funding for emergency departments and outpatient services which can often form one part of a broader primary health care service system. One response to the multiplicity of funders in this space is for one level of government (the Commonwealth) to take full responsibility for primary health care. While this option is not developed fully in these papers, the types of benefits that could accrue include improved connections across primary health care services, removal of perverse incentives on how services are funded and how that can impact on an ‘ideal’ patient journey and assist patient transitions.

Regardless of funding responsibilities between levels of governments, introducing a new model of chronic disease management would need to address a range of complex design and funding considerations including the need to determine:
  • targeting of populations for different levels of chronic disease management and how this would operate in practice;
  • range of services to be publicly funded, funding mechanisms to be adopted and how these could interact with existing mechanisms such as MBS rebated services, HACC services etc;
  • voluntary patient registration or enrolment arrangements which might be associated with a chronic disease management program, at what level these would occur and what conditions would apply to registration (noting that any arrangement would need to allow for patients’ ability to change practices/providers); and
  • integration across primary, specialist and acute care settings.
Before making an increased investment in chronic disease management, governments would also need to consider where this investment could be most effectively placed. Ideally, the goal of effective chronic disease management should be to 'upstage' or ‘upstream’ the impact of the disease – to slow or even halt the progression and ratchet back to more amenable intervention at an earlier stage. Targeting only that part of the population at the furthest end of the disease pathway will at best only shift the setting or place of care, not the type of care needed. It will also not reduce the continuing need for such care from new cohorts of patients nor the expense of treatment or the sequelae effects.

Evidence suggests that improved chronic care services focussed only on the high end/high need group provide limited overall benefit to the health system.223 Furthermore, interventions used earlier in the disease process may be more effective in preventing or at least delaying deterioration in health and hospitalisation.224

Self-management and other support provided by health advisors (eg at the time of or shortly following diagnosis of a chronic condition) can help individuals better manage their health through improved understanding of their condition, proactive identification of care gaps, influencing health behaviours, and actively monitoring patient health to help patients achieve their defined goals. Elements 1 and 2 also discuss important aspects of improved chronic disease management.

In the long-term, an effective model of chronic disease management would see stratification of the population with chronic disease and at risk of declining health to enable delivery of chronic disease care tailored to the particular needs, conditions and circumstances of individuals.

Summary – Key Future Directions

A National Primary Health Care Strategy provides the opportunity to strengthen and enhance existing arrangements to improve the continuity and coordination of care, particularly for those with complex care needs. Options include:
  • introduction of voluntary enrolment arrangements to encourage greater continuity and increased accountability for ongoing care;
  • development of clinical governance protocols to guide effective multi-disciplinary team care – to ensure teams understand individual roles and responsibilities;
  • support for adoption of evidentiary best practice – to encourage greater standardisation of care in line with evidence;
  • improved assessment tools and processes to improve targeting of available services according to individual clinical need;
  • greater flexibility in service delivery arrangements to most effectively tailor available services to individual need; and
  • most effective use of available workforce and support tools based on community need.
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185Public Health Information Development Unit, 2007. Atlas of Avoidable Hospitalisations in Australia: ambulatory care-sensitive conditions, AIHW Cat. no. HSE 49, AIHW, Canberra.

186Australian Institute of Health and Welfare, 2008. Australian hospital statistics 2006–07, Health services series no. 31. Cat. no. HSE 55, Australian Institute of Health and Welfare, Canberra.

187Australian Institute of Health and Welfare, 2009. Australian hospital statistics 2007–08, Health services series no. 33. Cat. no. HSE 71, pp. 49-50, 69-70 and Appendix 5, Australian Institute of Health and Welfare, Canberra.

188 The Commonwealth Fund, 2007. The Commonwealth Fund 2007 International Health Policy Survey in Seven Countries, available from: (accessed June 2009).

189 ibid.

190 ibid.

191 Professional Services Review, 2006. PSR Annual Report 2005-2006, available from: (accessed June 2009).

192 Harris M & Zwar N, 2007. Care of patients with chronic disease: the challenge for general practice, Medical Journal of Australia, vol. 187, no. 2, pp. 57-61.

193 ibid, pp. 104–107.

194 ibid, pp. 57-61.

195 Dennis S, Zwar N, Griffiths R, Roland M, Hasan I, Powell Davies G et al, 2008. Chronic disease management in primary care: from evidence to policy, Medical Journal of Australia, vol. 188, no. 8 (suppl), pp. S53-S56.

196 Ernst & Young, 2009. Review of Cardiovascular Disease Programs, Final Report, produced for the Australian Government Department of Health and Ageing, Canberra, p. 17.

197 Hofmarcher M, Oxley H, Rusticelli E, 2007. Improved Health System Performance through Better Care Coordination, OECD Health Working Paper No. 30.

198 ibid.

199 ibid.

200 GP Partners, 2008. Team Care Health II Perspectives – Fact Sheet, available from: (accessed June 2009).

201 Submission from South Australian Government (Sub #43)

202 Submission from The Royal Australian College of General Practitioners (Sub #173)

203 Submission from Australian General Practice Network (Sub #141)

204 Submission from Rural Doctors Association of Australia (Sub# 262)

205 Submission from Australian Practice Nurses Association (Sub # 203)

206 Submission from Australian College of Nurse Practitioners (Sub #104)

207 Submission from National Prescribing Service (Sub #103)

208 ibid.

209 Submission from Australian Psychological Society (Sub #231)

210 Submission from National Aboriginal Community Controlled Health Organisation (Sub #140)

211 Submission from Australian Chronic Disease Prevention Alliance (Sub #196)

212 Submission from Centre for Primary Health Care and Equity, University of NSW (Sub #168)

213 Submission from Australian Chronic Disease Prevention Alliance (Sub #196)

214 Submission from Southern General Practice Network (Sub #233)

215 Submission from Optometrists Association of Australia (Sub #258)

216 Submission from Consumers Health Forum (Sub #169)

217 Wagner E, Austin B, Davis C, Hindmarsh M, Schaefer J & Bonomi A, 2001. Improving chronic illness care: translating evidence into action, Health Affairs, vol. 20, no. 6, pp. 64-78.

218 Taylor W, 2007. Population management for chronic conditions – overview, Kaiser Permanente, Northern California.

219 Jones V, 2006. Managing Long Term Conditions – UK Solutions, Eastern Birmingham Primary Care Trust, England.

220 Mitchell G, Tieman J & Shelby-James T, 2008. Multidisciplinary care planning and teamwork in primary care, Medical Journal of Australia, vol. 188, no. 8 (suppl), pp. S61-S64.

221 Hofmarcher M, Oxley H & Rusticelli E, 2007. Improved Health System Performance through Better Care Coordination, OECD Health Working Paper No. 30.

222 ibid.

223 Hermiz O, Comino E, Marks G, Daffurn K, Wilson S & Harris MF, 2002. Randomised controlled trial of home based care of patients with chronic obstructive pulmonary disease, British Medical Journal, vol. 325, no. 938.

224 ibid.

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