NSW Chronic Disease Management Program – Connecting Care in the Community (CDMP) Service Model and Self-Assessment Process
The ACI has developed the NSW Chronic Disease Management Program – Connecting Care in the Community (CDMP) Service Model to describe the CDMP’s core principles, elements and resources. A Self-Assessment Tool has also been developed to assist Local Health Districts and Specialty Health Networks to assess the delivery of the program against the Service Model in order to identify local strengths and opportunities for improvement to inform quality improvement activities.
Local Health Districts and Specialty Health Networks are invited to use the following resources to undertake a CDMP self-assessment process in their area. The ACI Chronic Care team is available to support this process.
- CDMP Service Model
This Service Model is informed by current service delivery of the CDMP across the state. The Service Model describes the core elements and principles that underpin CDMP. It aims to build consensus and facilitate common understanding and communication about the CDMP in order to support the implementation and the ongoing development of the Program. The Service Model does not comprehensively describe local operational models in NSW. - CDMP Self-Assessment Tool
Completing the Tool will build a better understanding of how the service connects, and delivers quality person centred care across the range of chronic disease programs and services available to people with chronic disease. - CDMP Self-Assessment: Quality Improvement Process
An overview of the process to use the Self Assessment Tool to implement the Service Model.
Principles
The CDMP provides an integrated ‘whole of person’ approach to care for people who are at high and very high risk of hospitalisation as a result of their established and often multi-morbid chronic disease and complex needs. It recognises the need to provide person-centred care that considers carer and family needs, multi-morbidity and the socio-economic influences on health holistically, rather than in isolation from each other.
The principles of the CDMP are to:
- support the provision of coordinated, person-centred care that is empowering, respectful and appropriate
- enable the primary care sector to manage and support people with chronic disease as close to home as possible, ideally through a ‘medical home’ model. Hospital admissions related to chronic disease are often preventable if comprehensive care is provided in the community
- work in partnership to provide comprehensive and holistic care. The CDMP encourages a model of local shared governance with representation from LHDs, MLs, GPs, AMSs, chronic disease services and with input from NGOs and other community-based services
- implement evidence-based and evidence-informed care coordination and self-management support
- address health inequities especially for populations known to be at higher risk of hospitalisation including Aboriginal people, frail elderly people, people living in rural and remote locations, people from culturally and linguistically diverse backgrounds and people of low socio-economic status.
Core Elements
The core service elements of the CDMP are:
- targeted enrolment
- comprehensive assessment
- shared care planning
- service delivery in the form of care
- coordination and self-management support
- ongoing client monitoring and review.
Related initiatives
Contact
Rob Wilkins
A/Primary and Chronic Care Program Manager
Phone: +61 2 9464 4637 | 0401 406 307
rob.wilkins@health.nsw.gov.au