Indigenous Chronic Disease Package
Specialist Outreach Programs and Care Coordination
Table of contents
- Improve your Aboriginal and Torres Strait Islander patients’ health
- GP and Patient Journey flowchart
How to participate in this program- Registering your practice/service for the PIP Indigenous Health Incentive
- Registering your eligible patients for the PBS Co-payment measure
- Cultural awareness training: who needs it?
- Defining ‘chronic disease’ and ‘at risk’
- Identifying and signing up eligible patients
- Specialist Outreach Programs and Care Coordination
- Indigenous Health Project Officers: A resource for General Practices and Indigenous Health Services
- Aboriginal and Torres Strait Islander Outreach Workers
- Chronic disease self-management accredited training for staff
- National Tackling Smoking Workforce
- Healthy Lifestyle Workers
- MBS Item numbers for Aboriginal and Torres Strait Islander health services
- General restrictions
The following three initiatives all aim to improve the access of Aboriginal and/or Torres Strait Islander patients with chronic disease to specialist and allied health medical services. These measures focus on developing multidisciplinary approaches to care and can assist GPs in the development and implementation of a comprehensive and team approach to care.
Medical Specialist Outreach Assistance Program – Indigenous Chronic Disease (MSOAP-ICD) measure
The MSOAP provides rural and remote communities with increased access to medical specialist services. As part of the Australian Government’s commitment to tackling Aboriginal and Torres Strait Islander chronic disease, the MSOAP has been expanded to introduce multidisciplinary teams, comprising medical specialists, GPs and allied health professionals, to better manage chronic health conditions in rural and remote Aboriginal and Torres Strait Islander communities.Urban Specialist Outreach Assistance Program (USOAP)
The USOAP provides access for Aboriginal and/or Torres Strait Islander patients with a chronic disease to outreach medical specialist care in urban areas and inner regional areas.Care Coordination and Supplementary Services (CCSS) Program
Developing multidisciplinary approaches to care requires significant coordination. General practices and Indigenous Health Services implementing care plans for patients with chronic disease will be able to refer patients identified as needing more complex chronic disease management, or support to access services, to the CCSS Program once it is established in their region, provided they have registered for the PIP Indigenous health Incentive.The CCSS Program will provide assistance to Aboriginal and/or Torres Strait Islander patients
including:
- arranging the health services required;
- ensuring there are arrangements in place for the patient to get to appointments;
- transferring and updating a patient’s medical records;
- assisting the patient to participate in regular reviews by their primary care provider;
- adherence to treatment regimes (eg. medication compliance);
- development of chronic condition self-management skills; and
- connection with appropriate community based services such as those providing support for daily living.
For more information, contact your local Division of General Practice or visit: http://agpn.com.au/divisions-directory
5 Department of Health and Ageing. Closing the Gap: Tackling Indigenous Chronic Disease. Canberra:DOHA;2010. Available at :http://www.health.gov.au/internet/ctg/publishing.nsf/Content/Improving-Chronic-Disease-Managementand-Follow-up