Indigenous Chronic Disease Package
Defining ‘chronic disease’ and ‘at risk’
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 aim of the Australian Government’s Indigenous Chronic Disease Package is to assist in closing the life expectancy gap between Indigenous and non-Indigenous Australians.
The package is designed to improve the prevention, early detection and ongoing management of those chronic diseases that are the main causes of mortality for Aboriginal and Torres Strait Islander people such as cardiovascular disease, diabetes, chronic respiratory disease, cancer and chronic renal disease.
‘Chronic disease’
The MBS definition of a chronic disease is:“A disease that has been, or is likely to be, present for at least six months, including but not limited to asthma, cancer, cardiovascular illness, diabetes mellitus, musculoskeletal conditions and stroke”.
Where a patient has a mental health condition as well as a chronic or terminal condition and complex care needs requiring team based care, the GP can use both GP Management Plan and Team Care Arrangements; and GP Mental Health Treatment Plan.
‘At risk’
The PBS Co-payment measure recognises that the risk of developing chronic disease over a person’s lifetime is influenced by complex biological, environmental and socially determined factors and could include, for example:- in utero and early childhood factors, such as low birth weight and recurrent childhood infections. It is recognised that developmental health problems play a critical role in future health outcomes;
- behavioural and biological factors, such as smoking, physical inactivity, poor nutrition, family history of chronic disease, high blood pressure and cholesterol; and
- social and economic factors, such as financial hardship, substance abuse and emotional well-being.
Prescribers are encouraged to use clinical judgment to determine whether a patient has risk factors for chronic disease.