Better health and ageing for all Australians

Aboriginal and Torres Strait Islander Health Performance Framework (HPF) 2012

Tier 3—Continuous—3.18 Care planning for chronic diseases

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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 1.02 and 1.23). 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 informed responsibility for their care, including actions to help achieve the goals of treatment. A care plan may involve one health professional (usually a GP or other primary health care doctor), or may be negotiated with several service providers (e.g., GP, nurse, Aboriginal health worker, allied health professionals, community services providers) in consultation with the patient.

A recent review of evidence found that chronic disease interventions most likely to be effective in the Australian context were: engaging primary care services 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 items under the Medicare 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 was an increase in the number of GP management plan services claimed by Indigenous Australians between 2009–10 and 2010–11 (from 23,972 to 32,717). After adjusting for differences in age structures of the two populations, Indigenous Australians received more claimed GP management plans than non-Indigenous Australians (102 per 1,000 compared to 55 per 1,000). There was also an increase in the number of team care arrangements claimed (from 18,680 to 26,525). Indigenous Australians also had a higher rate of nurse/Aboriginal Health Worker consultations claimed than non-Indigenous Australians (522 per 1,000 compared with 257 per 1,000) and team care arrangements (83 per 1,000 compared to 45 per 1,000).

Data from services funded under the Healthy for Life program show that of the 11,928 Indigenous adults with Type 2 diabetes who were regular clients of Healthy for Life services, 3,112 (26%) had a GPMP (or equivalent) as at 30 June 2010. Rates were higher in inner regional areas (37%) and lowest in major cities (17%). Of the 3,668 Indigenous adults with coronary heart disease who were regular clients of the Healthy for Life service, 1,062 (29%) had a GPMP or equivalent. Rates were higher in very remote areas (36%) followed by remote areas (35%) and lowest in major cities (17%). Team care arrangements for diabetes and coronary heart disease patients increased from 3–4% in 2007 to 23% in 2010.

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 & ACMA 2005). In 2004–05, it was estimated that 25% of Aboriginal and Torres Strait Islander peoples 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). Indigenous Australians with asthma living in NSW had the highest proportion with a written asthma plan and the lowest proportion was in WA (17%).

Information on the management of chronic conditions by Aboriginal and Torres Strait Islander primary care services is available through the OATSIH Services Reporting system (see measure 3.05). In 2010–11, 92% of services provided care planning and 74% reported that discharge planning was well coordinated between the hospital and the service. In 2010–11, 80% of services provided or facilitated shared care arrangements for the management of people with chronic conditions.Top of Page

Implications:

As discussed in relation to measure 3.05 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). Working with clients and their families to support proactive management of health conditions is vital (Griew et al. 2007).

Currently the Australian Government provides funding through the Practice Incentives Program – Indigenous Health Incentive to support general practices and Indigenous health services to provide best practice management of chronic disease. Chronic disease management is vital for closing the gap in Indigenous life expectancy (see measure 3.05).Top of Page
Figure 192—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 192—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 NHS
Table 49—Number and proportion of Indigenous regular clients of services funded through the Healthy for Life program with a chronic disease who have a current GPMP and/or an equivalent alternative, by type of chronic disease and remoteness, at 30 June 2009
Top of PageNumber of Indigenous regular clients with a current GPMP and/or alternative:
Major CitiesInner RegionalOuter RegionalRemoteVery RemoteTotal
Type 2 Diabetes
3605398447666033112
Coronary Heart Disease
1552153322411191062
Total number of Indigenous regular clients with a chronic disease:
Major CitiesInner RegionalOuter RegionalRemoteVery RemoteTotal
Type 2 Diabetes
2158147435262673209711928
Coronary Heart Disease
90464211056833343668
Proportion of Indigenous regular clients with a chronic disease who have a current GPMP and/or alternative (%):
Major CitiesInner RegionalOuter RegionalRemoteVery RemoteTotal
Type 2 Diabetes
16.736.623.928.728.826.1
Coronary Heart Disease
17.133.53035.335.629
Source: AIHW, Healthy for Life data collection
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Table 50—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 TCA, by type of chronic disease, at 30 June 2007, 2008, 2009 and 2010
Type 2 Diabetes:
2007
2008
2009
2010
Number of Indigenous regular clients with a current TCA
85
931
1520
2566
Total number of Indigenous regular clients with Type 2 diabetes
2252
7084
7905
11230
Proportion who have a current TCA (%)
3.8
13.1
19.2
22.8
Coronary Heart Disease:
2007
2008
2009
2010
Number of Indigenous regular clients with a current TCA
28
na
415
792
Total number of Indigenous regular clients with coronary heart disease
956
na
2294
3510
Proportion who have a current TCA (%)
2.93
na
18.1
22.6
Source: AIHW, Healthy for Life data collection
Figure 193—Number of GPMPs and TCAs claimed through Medicare, Indigenous Australians, 2009–10 and 2010–11
Top of PageFigure 193—Number of GPMPs and TCAs claimed through Medicare, Indigenous Australians, 2009–10 and 2010–11
Source: Medicare Australia
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