Aboriginal and Torres Strait Islander Health Performance Framework - 2010

3.16 Care planning for clients with chronic diseases

Page last updated: 26 May 2011

Why is it important?:

Chronic diseases such as circulatory disease, diabetes, renal disease, chronic respiratory disease, cancers and chronic mental health conditions are a major cause of morbidity and mortality among Aboriginal and Torres Strait Islander peoples (see measure 1.23 and 1.02). Effective management of chronic disease can delay the progression of disease, decrease the need for high-cost interventions, improve quality of life, and increase life expectancy. As good quality care for people with chronic disease generally involves multiple health care providers across multiple settings, the development of care plans is one way in which the client and primary health care provider can ensure appropriate care is arranged and coordinated.

A care plan is a written action plan containing strategies for delivering care that address an individual’s specific needs, particularly patients with chronic conditions and/or complex care needs. A care plan can be used to record comprehensive, accurate and up to date information about the patient's condition, actions the patient needs to take, the various services required and collaboration with other service providers to achieve management goals for the patient. Development of a care plan can also help encourage the patient to take some responsibility for their care, including the identification of any actions the patient might take to help achieve the goals of treatment. A care plan may involve one health professional (usually a GP or other primary health care doctor) and patient, or may be negotiated with several service providers (e.g. GP, nurse, Aboriginal health worker, allied health professionals, community services providers) in liaison with the patient.

A recent review of evidence concerning chronic disease management interventions in primary care settings in Australia found that interventions most likely to be effective in the Australian context were: engaging primary care in self-management support through education and training for GPs and practice nurses, and including self-management support in care plans linked to multidisciplinary team support (Dennis et al. 2008). A study of general practice patients with Type 2 diabetes found that following implementation of a care plan the proportion of patients involved in multi-disciplinary care and in the adherence to diabetes care guidelines increased. There were also improvements in patients’ metabolic control and cardiovascular risk factors (Zwar et al. 2007).

GPs are encouraged to develop care plans through a number of primary care items under the Medical Benefits Schedule. In July 2005, new Chronic Disease Management items were introduced specifically focused on patients with chronic or terminal conditions who will benefit from a structured approach to management of their care needs (DoHA 2008b). These include an item related to the development of General Practitioner Management Plans (GPMPs), an item for a Team Care Arrangement (TCAs) where planning involves a broader team and items for where GPs contribute to the care plans developed by another service provider and reviews of those plans.

Aboriginal and Torres Strait Islander primary health care services have been facilitating care planning for their patients across the health system and with other sectors since the inception of the first services (Central Australian Aboriginal Congress 2004).

Findings:

Medicare claims data show that there were 23,927 GP management plan services claimed by Indigenous Australians during 2009–10. After adjusting for differences in age structures, Indigenous Australians received more claimed GP management plans than non-Indigenous Australians (76 per 1,000 compared to 47 per 1,000). Indigenous Australians also had a higher rate of nurse/Aboriginal Health Worker consultations claimed than non-Indigenous Australians (578 per 1,000 compared with 327 per 1,000) and team care arrangements (60 per 1,000 compared to 37 per 1,000).

Data from services funded under the Healthy for Life program show that of the 8,535 Indigenous adults with Type 2 diabetes who are regular clients of Healthy for Life services, 2,813 (33%) had a GPMP (or equivalent). Of the 2,395 Indigenous adults with coronary heart disease who are regular clients of the Healthy for Life service, 691 (29%) had a general practitioner management plan or equivalent. Take-up of these items was higher for services located in regional (26–29%) and remote (38–39%) areas compared with services in urban areas (18–20%). These rates have all improved since last measured in 2007. Take-up of items for TCAs has increased from 3–4% in 2007 to 18–19% in 2009.

Key elements of effective asthma management include the development of a written asthma action plan and regular use of medications that control the disease and prevent exacerbations of the condition (AIHW Australian Centre for Asthma Monitoring 2005). In 2004–05, it was estimated that 25% of Aboriginal and Torres Strait Islander people with asthma, living in non-remote areas, had a written asthma plan, compared with 22% of non-Indigenous Australians. However, for some age groups this pattern was reversed (e.g. 5–24 and 45–54 year age groups). The prevalence of asthma is higher for Indigenous people (18% of the population compared with 10% for non-Indigenous Australians).

Information on the management of chronic conditions by Aboriginal and Torres Strait Islander primary care services is available through the OATSIH Service Reporting system (see measure 3.04). In 2008–09, 91% of services provided care planning and 67% reported that discharge planning was well coordinated between the hospital and the service. In 2008–09, 78% of services provided or facilitated shared care arrangement for the management of people with chronic conditions.

Implications:

As discussed in relation to measure 3.04, the provision of organised chronic disease management in Aboriginal and Torres Strait Islander primary health care services has been demonstrated to result in improvement in various health outcomes (Hoy et al. 1999; Hoy et al. 2000; Rowley et al. 2000; McDermott et al. 2003; Bailie et al. 2007). Care planning is one of the important elements in effective chronic disease management (Vagholkar et al. 2007).

Currently the Australian Government provides funding through the Practice Incentives Program (PIP) Indigenous Health Incentive to support general practices and Indigenous health services to provide best practice management of chronic disease. Health services participating in this program are also able to refer Aboriginal and Torres Strait Islander clients needing more complex care to the new Care Coordination and Supplementary Services Program. Chronic disease management for Indigenous Australians is vital for closing the gap in Indigenous life expectancy (see measure 3.04).

Figure 178 – Proportion of people with asthma reporting that they have a written asthma action plan by Indigenous status and age group, non-remote areas, 2004–05


Figure 178 – Proportion of people with asthma reporting that they have a written asthma action plan by Indigenous status and age group, non-remote areas, 2004–05
Source: AIHW analysis of 2004–05 NATSIHS and 2004–05 National Health Survey
Text description of figure 178 (TXT 1KB)

Table 70 – Number and proportion of Indigenous regular clients of services funded through the Healthy For Life program with a chronic disease who have a current General Practitioner Management Plan and/or an equivalent alternative, by type of chronic disease and remoteness, at 30 June 2009

Urban
Regional
Remote
Total
Number of Indigenous regular clients with a current GPMP and/or alternative:
Type 2 Diabetes
261
705
1,847
2,813
Coronary Heart Disease
108
218
365
691
Total number of Indigenous regular clients with a chronic disease:
Type 2 Diabetes
1,302
2,422
4,811
8,535
Coronary Heart Disease
606
844
945
2,395
Proportion of Indigenous regular clients with a chronic disease who have a current GPMP and/or alternative (%):
Type 2 Diabetes
20.0
29.1
38.4
33.0
Coronary Heart Disease
17.8
25.8
38.6
28.9
Source: AIHW, Healthy for Life data collection

Table 71 – Number and proportion of Indigenous regular clients of services funded through the Healthy For Life program with a chronic disease who have a current MBS item 723 Team Care Arrangement, by type of chronic disease, at 30 June 2007, 2008 and 2009

30 June:
2007
2008
2009
Type 2 Diabetes:
Number of Indigenous regular clients with a current TCA
85
931
1,520
Total number of Indigenous regular clients with Type 2 diabetes
2,252
7,084
7,905
Proportion who have a current TCA (%)
3.8
13.1
19.2
Coronary Heart Disease:
Number of Indigenous regular clients with a current TCA
28
na
415
Total number of Indigenous regular clients with coronary heart disease
956
na
2,294
Proportion who have a current TCA (%)
2.9
na
18.1
Source: AIHW, Healthy for Life data collection

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