Integrated Chronic Disease Management encompasses the 2 areas of PCP work referred to as:
- Early Intervention and Integrated Care and,
- Client and Community Empowerment.
Early Intervention and Integrated Care Early Intervention and Chronic Disease (ELiCD) aims to improve how people with chronic disease manage their condition, prevent complications, and improve their health and well-being. South Coast PCP supports services to help people living with chronic disease, encouraging new approaches that are consistent with evidence-based chronic care. It also supports work to improve care coordination for people who access multiple services over long periods. That is, it encourages integrated chronic disease management (ICDM). Integrated care brings together inputs, delivery, management and organisation of services related to diagnosis, treatment, care, rehabilitation and health promotion. Integration is a way to improve access, quality and the patient experience. Aspects of South Coast PCP work supporting agencies to implement robust patient referral and feedback processes and communication between health services, development and implementation of localised care pathways and identifying and responding to barriers to accessing services.
Client and Community Empowerment When health services are provided consumers, carers and community members should be meaninfully involved in decision making about health planning, care and treatment and the wellbeing of themselves and the community. South Coast PCP supports agencies to consider consumers and carers in aspects of health planning and service delivery. Aspects of South Coast PCP work, such as health literacy, care planning, National Health Services Directory, person centred care and chronic disease self-management, support member agencies implementing service which support consumer and community empowerment.