2 Table of Contents Introduction Transitions Program Pillars General Principles Regarding Admission Cancer Cirrhosis Congestive Heart Failure COPD Dementia Geriatric Frailty Syndrome Referral Process Appendix A: Palliative Performance Scale (PPS) As our need for improved chronic care grows, health care delivery systems are trying to correct the many deficiencies in current management of chronic diseases. hypertension. Self-management education is recommended for those with chronic illnesses by a variety of professional organizations. The Chronic Disease Management (formerly Enhanced Primary Care or EPC) — GP services on the Medicare Benefits Schedule (MBS) enable GPs to plan and coordinate the health care of patients with chronic or terminal medical conditions, including patients with these conditions who require multidisciplinary, team-based care from a GP and at least two other health or care providers. dementia. 53 The impetus for developing IMR initially arose at a Robert Wood Johnson Foundation Consensus conference of … Chronic Disease Self-Management Program Updated/reviewed December 2019. This program is led by pairs of trained lay leaders to groups of ten to sixteen people once each week for 2 and ½ hours for six consecutive weeks. chronic obstructive pulmonary disease (COPD) schizophrenia . The NSW Chronic Disease Management Program (CDMP) – Connecting Care in the Community provided care coordination and self-management support to help people with chronic disease to better manage their condition and access appropriate services. Under the Chronic Management Program, a chronic care management program, the insured person will be entitled to manage medical expenses for out-patient treatment of Diabetes, Hypertension, Hyperlipidaemia and Asthma, as specified in the policy schedule, Medical Practitioner’s consultations. Common chronic conditions include cancer, heart disease and diabetes. Need: To help people with chronic conditions learn how to manage their health. hypertension. To begin accessing each module, click on 'course catalogue' at the top of the page.
The Chronic Disease Management Program (CDMP) combines two programs: Pulmonary Rehabilitation and the Heart Failure Program. The Flinders Chronic Condition Management Program (henceforth referred to as The Flinders Program) is a generic set of tools and processes enabling health professionals to support their clients to more effectively self-manage their chronic condition(s).
asthma . Complex chronic care management services, with the following required elements: Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
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