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• Indigenous Chronic
  Disease Package
• Tackling Chronic Disease
  Risk Factors
  • National action to reduce Indigenous smoking rate
  • Helping Indigenous Australians to reduce their risk of chronic disease
  • Local Indigenous community campaigns to promote better health
• Improving Chronic Disease
  Management and Follow up
  • Subsidising PBS medicine co-payments
  • Higher utilisation costs for MBS and PBS
  • Supporting primary care providers to coordinate chronic disease management
  • Improving Indigenous participation in health care through chronic disease self management
  • Increasing specialist and allied health follow up care
  • Monitoring and evaluation
• Workforce Expansion,
  Training and Support
  • Workforce education and training
  • Expanding the outreach and service capacity of Indigenous health services
  • Engaging Medicare Locals to improve Indigenous Access to mainstream primary care
  • Attracting more people to work in Indigenous Health
  • Clinical practice and decision support

Indigenous Chronic Disease Package

Improving care coordination

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Access to ongoing care, including specialist care provided by members of a multidisciplinary team, is important to good chronic disease management. People with chronic conditions need to be connected to the health system and support networks. This assists people to:

• understand their condition(s) and treatment options;
• have a care plan in place, with opportunities to monitor and review the plan;
• take steps to protect and promote health;
• monitor and manage any ongoing symptoms or signs of the condition(s); and
• have confidence in their ability to access and use local support services.

A range of supports are in place to improve access to and the affordability of follow-up care.

On 1 May 2010, the Medicare Benefits Schedule (MBS) was amended to allow Practice Nurses and Aboriginal Health Workers to provide additional follow-up care after an Aboriginal and Torres Strait Islander Health Assessment. This was increased from five to 10 MBS billable care items per year, per Aboriginal and Torres Strait Islander person.

Flexible funding through the Care Coordination and Supplementary Services Program:

• provides care coordination to assist individual clients to access follow-up services consistent with their care plan; and
• overcomes barriers that reduce access to follow-up care provided by allied health professionals and medical specialists.

Indigenous Health Services and general practices participating in the PIP Indigenous Health Incentive may refer clients with chronic disease and complex care needs to the Care Coordination and Supplementary Services Program. These services operate at a regional level to provide care coordination to ensure clients can access the necessary follow-up care recommended by their GP in their care plan. This program will begin operations in a limited number of locations from September 2010 and will grow over the next few years.

Improving access to specialist care

The Medical Specialist Outreach Assistance Program (MSOAP) has been expanded to introduce multidisciplinary teams comprising specialists, general practitioners and/or allied health professionals to better manage complex and chronic health conditions in rural and remote Aboriginal and Torres Strait Islander communities.

Access to specialist care will also be improved by the Urban Specialist Outreach Assistance Program (USOAP) which began in May 2010. This program will support medical specialists to provide outreach services in urban areas and assist with the cost of specialist follow-up care for Aboriginal and Torres Strait Islander people. The service has started in New South Wales and will be progressively rolled out in major cities around Australia from 2010-11.

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Page currency, Latest update: 09 December, 2010

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