Chronic condition management

Nggangganawili Aboriginal Health Service strives to ensure that patients with chronic conditions receive continuing care and management according to regularly reviewed health plans.

In our 2008-2012 Strategic Plan we identify a key objective to reduce hospital admissions of people in the community for chronic disease complications. Our long term target is a 30% reduction.

To achieve this objective we will:     

• Implement culturally appropriate and evidence-based Care Management Plans for diabetes, coronary heart disease, and respiratory disorders
• Explore feasibility of extending the application of care plans across a wider range of chronic diseases and other health issues
• Facilitate staff professional development opportunities in the area of chronic disease management
• Develop and implement health promotion programs and resources to ensure comprehensive and consistent information is provided to patients relating to chronic disease management
• Our targets to achieving this objective in the short term are:
• Ensure our register of people with clients diagnosed with diabetes, coronary heart disease, and respiratory disease is accessible by health service staff and visiting specialists
• Enhance our system for Care Management Plans is implemented and incorporated into the Patient Information Recall System
• Ensure relevant information is incorporated into the NAHS Health Promotion Program staff resource kit
• Commence bi-annual reporting of service achievements against performance targets to NAHS Executive Management Committee
• Ensure staff are engaged in professional development training on health indicators and evidence based practice in the management of chronic diseases
• Commence weekly clinical team meetings involving nurses, health workers, doctors, allied health workers to review and discuss clinical related issues
• Ensure information about chronic disease risk factors is disseminated through the Building Healthy Communities  program