Perspectives
General medicine
Volume 209 - Issue 2

Care of patients with chronic disease: achievements in Australia over the past decade

Authors:  Mark F Harris, Ben Harris-Roxas and Andrew W Knight

Med J Aust 2018; 209 (2): 55-57. || doi: 10.5694/mja18.00333
Published online: 16 July 2018

Despite progress made in chronic disease management in Australia, there is an ongoing need for better quality of care and services integration, as rates of chronic disease and multimorbidity continue to rise

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Rising rates of chronic disease and multimorbidity require better quality of care and services integration

A decade ago, our review called for better integrated and more comprehensive chronic disease management.1 Chronic conditions continue to be the major challenge confronting the Australian health system, with more than half of the adult population reporting long term conditions.2 Premature mortality rates have declined, especially for cardiovascular disease, although it remains the leading cause of preventable death.3 Survival from cancer has increased — with greater demands on patients and services as survivors may have complications or comorbidities.4 Addressing smoking, poor nutrition, hazardous alcohol consumption, and physical inactivity as behavioural risk factors is essential to the control of long term conditions and their complications. There has been some success with tobacco use declining to 13% of the population, although it still accounts for the largest contribution to the burden of disease. Nevertheless, other risk factors have not improved. For example, the proportion of Australians who are overweight or obese (body mass index, ≥ 25 kg/m2) increased from 61% in 2007–08 to 63% in 2014–15.5

Primary care continues to play a central role in the detection and management of long term conditions, with increased emphasis on multimorbidity. In 2015–16, the BEACH (Bettering the Evaluation and Care of Health) study reported that chronic problems were managed in more than half of general practice encounters — a similar rate to 2007.6 The proportion of patients aged 65 years and over with two or more long term conditions has risen from more than half in 2007 to three-quarters of patients in 2015.7

Changes to the model of care

The approach to the management of chronic disease has developed considerably in Australia over the past decade. The previous National Chronic Disease Strategy in 2006 focused on five priority conditions (ie, asthma, cancer, diabetes, cardiovascular diseases and musculoskeletal conditions) and the policy drivers were the need for prevention and planned multidisciplinary rather than episodic care.8 This strategy has been replaced by a framework that has a broader view, including a focus on shared determinants and risk factors for chronic disease and multimorbidities and is more aligned with the United Nations and the World Health Organization policy.9,10 While the chronic care model still has salience, there has been increasing emphasis on the need for greater integration of care between primary and specialist services. This is in recognition of the significant gaps in our fragmented health system.11,12 Measures introduced to improve the integration of care include the development of codified assessment and referral pathways and shared information systems, including the establishment of My Health Record (www.myhealthrecord.gov.au), although this does not yet allow sharing of care plans. The role of practice nurses has developed, especially in the prevention, assessment and planning of chronic disease care.13 Self-management support and coaching is more available, and efforts at care coordination have been initiated through state health services.14 There has also been some limited use of telehealth, risk stratification and proactive outreach to patients enrolled in coordinated care.

Access and quality

Access to primary care in Australia is high compared with Organisation for Economic Cooperation and Development countries.15 However, barriers to access exist for both low income individuals and people in rural areas.16,17 There are also major challenges in ensuring that care is appropriate to the patients’ level of health literacy, culture and language.18 The use of the national telephone interpreter service is free for general practitioners, but other health professionals do not have the same level of access.19 Most Australians have low health literacy, yet there are no systematic efforts to improve population health literacy or to deal with the complexity of the web of services they need to navigate.20,21 There is increasing recognition that patients with long term physical conditions such as diabetes are at risk of depression and that these require collaborative models of care, which has not been widely addressed.22 Furthermore, many patients with serious mental illness or drug and alcohol problems still receive poor preventive care and management of their long term conditions, contributing to their low life expectancy.23

Care planning and multidisciplinary team care

Care planning has been a major strategy for achieving more systematic care of long term conditions. Research on patients with diabetes suggests that reviews of care plans and multidisciplinary care involving practice nurses and allied health services are associated with reducing the risk of hospitalisation.24-26 The use of GP Management Plans and Team Care Arrangements has climbed steadily since their introduction in 2005 (Box 1). The number of case conferences has increased but is still much lower than the other items. The claims for practice nurse and allied health services in association with the GP care planning items have also increased dramatically since 2007 (Box 2). Despite this trend, multidisciplinary teams within primary care and collaborative care with specialist services are infrequent even in services designed to achieve this.27

Incentives for structured chronic disease management exist in the current Practice Incentives Program (PIP) for diabetes and asthma care. There is some limited evidence for the positive impact of these processes of care on hospitalisation.25 The Australian Government has foreshadowed that these and other PIP incentives will change to have more emphasis on data collection for quality improvement. The ability of general practice to extract practice data on population and chronic disease management indicators is now reasonably widespread, which is partly the legacy of the Australian Primary Care Collaboratives Program. However, data capture and analysis at the Primary Health Network level are not fully developed.

Barriers

Chronic disease management in Australian primary care has matured since 2007. Despite this, barriers remain, with up to a third of patients with chronic conditions not receiving optimal management and reporting problems with care coordination.16,28,29 Box 3 outlines some of these barriers and suggests some possible ways in which these could be managed. The health service and system context in which innovations in chronic disease management have been implemented is complex and requires providers to understand the change, be committed to it and make a continuing investment in changes to roles, resources and relationships.30

Australia is looking abroad for models of care that can deal with some of these barriers and deliver better outcomes for patients with, or at risk of, chronic disease in primary care. Considerable hope is placed on the patient-centred medical home model, with the establishment of a trial by the Australian Government in 179 practices and Indigenous community-controlled health services in ten Primary Health Networks. The trial includes enrolment of patients with chronic disease, risk stratification, individual shared care plans, and bundled payment. Its evaluation should inform debate about the value of capitated compared with fee-for-service payment for patients with chronic disease.

Conclusion

Some progress has been made in chronic disease management in Australia over the past decade. However, there is an ongoing need for better quality of care and integration between primary care and specialist and hospital services, and for scaling up the promising activities that have still not been fully implemented. This need has become more acute as rates of chronic disease and multimorbidity continue to rise, placing greater demands on the health system and costs for the community.

Box 1 – Medicare claims for chronic disease management in general practice, 2005–2017

GPMP = GP Management Plan. TCA = Team Care Arrangement. Items 735, 739 and 743 are for organising a case conference. Source: Australian Government Department of Human Services. Medicare items processed from January 2005 to December 2017.

Box 2 – Nursing and allied health item claims for patients with chronic disease, 2005–2017

AHW = Aboriginal and Torres Strait Islander Health Practitioner health worker. PN = practice nurse. Source: Australian Government Department of Human Services. Medicare items processed from January 2005 to December 2017.

Box 3 – Some current barriers to optimal management of chronic conditions in general practice

Barrier

Contributing factors

Potential solutions

Effective integration of care

Despite team care plans and some attempts at collocated models, there is fragmentation between services

Interoperable information systems
Care plans that are shared and interacted with by all providers

Tailoring care to patients

Self-management programs and coaching programs not tailored to variability in patients’ health literacy, culture, language skills and level of patient activation

Increased availability of multilingual programs
Assessment and tailoring to patients’ health literacy and activation levels

Management of practice population

Few practices have systematically assessed the level of risk for chronic diseases of their practice population to tailor proactive care
Limited capacity of practice staff to conduct outreach and care navigation

Enrolment
Implementation of tools to assess risk in the practice population
Community health workers and/or patient navigators as phone and outreach workers

Funding models

Fee-for-service funding which does not adequately fund services which are not face-to-face time or share team responsibility
Different accountability for general practice, allied health, non-government organisations and state health services

Flexible funding based on enrolled patients with long terms conditions
Shared accountability for care outcomes

 

Authors

  • Mark F Harris1
  • Ben Harris-Roxas1
  • Andrew W Knight1,2
  • 1. Centre for Primary Health Care and Equity, University of New South Wales, Sydney, NSW
  • 2. Improvement Foundation, Adelaide, SA

Correspondence: m.f.harris@unsw.edu.au

Competing interests

No relevant disclosures.

References

Provenance: Commissioned; externally peer reviewed.

View this article on Wiley Online Library

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