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3.18 Care planning for chronic diseases

Why is it important?

Chronic diseases are the major causes 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 information about the patient's condition, actions the patient needs to take and the various services required 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 treatment goals. 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 number of reviews have found that the chronic disease interventions most likely to be effective in the Australian context include: 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 (Kowanko 2012; Dennis et al. 2008). A study of general practice patients with Type 2 diabetes found that, following implementation of care plans, the proportion of patients involved in multidisciplinary 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. These include an item related to the development of GP Management Plans (GPMPs), an item for Team Care Arrangements (TCAs) where planning involves a broader team, and items for where GPs contribute to care plans developed by another service provider or to a review of those plans.

Findings

In 2013–14, there were around 53,600 Medicare GPMP claims and 44,400 TCA claims for Indigenous Australians—a steady increase in uptake since these items were introduced in July 2005. In the five years from 2009–10 to 2013–14, rates of services claimed by Indigenous Australians have doubled for GPMPs (from 55 to 114 per 1,000) and more than doubled for TCAs (from 44 to 96 per 1,000).

In 2013–14, the Indigenous rate was higher than the non-Indigenous rate for both GPMPs (114 per 1,000 compared with 72 per 1000) and TCAs (96 per 1,000 compared with 58 per 1,000). This higher rate for Indigenous Australians has been particularly noticeable from 2009–10 when the Indigenous chronic disease initiatives were introduced. In 2013–14, Indigenous Australians also had a higher rate of practice nurse/Aboriginal health worker consultations claimed (236 per 1,000 compared with 39 per 1,000).

Australian Government-funded Indigenous primary health care organisations provide national Key Performance Indicators data on a range of process of care measures related to chronic disease management. In December 2013, around 28,000 regular Indigenous clients of these organisations had Type 2 diabetes. Of these clients, 47% had a GPMP in the two years to December 2013. This was an increase of 6 percentage points from December 2012. In that period, inner regional and very remote areas showed improvement of over 6 percentage points. Of clients with diabetes, 44% had a TCA in the two years to December 2013. This was an increase of 7 percentage points from December 2012. Improvements were seen in most jurisdictions; outer regional was the only area not to show an improvement (AIHW 2014w).

In 2012–13, Online Services Report data from Australian Government-funded Indigenous primary health care organisations included organisation-level data on chronic disease management. Of the 205 organisations, 98% provided care planning. Of those, 63% reported that discharge planning was well coordinated between the hospital and the organisation and 62% provided or facilitated shared-care arrangements for managing people with chronic conditions.

Key elements of effective asthma management include a written asthma action plan and regular use of medications that control the disease and prevent exacerbations of the condition (AIHW 2011b). Self-reported data from the 2012–13 Health Survey, indicate that 29% of Aboriginal and Torres Strait Islander peoples with asthma living in non-remote areas had a written asthma action plan. After adjusting for differences in the age structures of the two populations, this rate was similar to the proportion for non-Indigenous Australians. Rates were highest for children aged 0–14 years. Indigenous Australians were more likely to go to hospital or an emergency department due to their asthma than non-Indigenous Australians, particularly in the age groups over 25 years. Indigenous Australians with asthma living in the NT had the highest proportion with a written asthma plan (37%) and the lowest proportion was in the ACT (22%). Based on self-reported data from the 2012–13 Health Survey, 18% of Indigenous Australians had asthma—twice the non-Indigenous rate.

Implications

As discussed in relation to measure 3.05, 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. 2000; Hoy et al. 1999; 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 Programme—Indigenous Health Incentive, which aims to support general practices and Indigenous health services to provide better health care for Aboriginal and Torres Strait Islander patients, including best practice management of chronic disease.

Other local arrangements also exist. For example, the NT Department of Health Chronic Condition Management Model seeks to improve coordination and delivery of services, and has demonstrated an increase in the proportion of chronic condition clients with a GPMP (increasing from 40% in June 2012, to 51% in May 2014) (NT Department of Health 2014).

Figure 3.18-1 Proportion of people with asthma reporting they have a written asthma action plan, by Indigenous status and age group, non-remote areas, 2012–13
chart showing Proportion of people with asthma

Figure 3.18-1 shows the proportion of Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians with asthma reporting that they have a written asthma action plan in non-remote areas in 2012–13. Data is presented separately for the following age groups: 0-4 years, 5-14 years, 15-24 years, 25-34 years, 35-44 years, 45-54 years, and 55 years and over. The figure shows that the proportions of Australians with asthma living in non remote areas that had a written asthma action plan were similar for Indigenous and non-Indigenous Australians across each of the age-groups. Rates were highest for children aged 0–14 years.

Source: ABS and AIHW analysis of 2012–13 AATSIHS

Figure 3.18-2 Age-standardised rates of GPMPs and TCAs claimed through Medicare, by Indigenous status, 2005–06 to 2013–14
chart showing Age-standardised rates

Figure 3.18-2 shows the annual age-standardised rate (number per 1,000 population) of GP Management plans and Team Care Arrangements claimed through Medicare among Indigenous Australians from 2005-06 to 2013-14. In the five years from 2009–10 to 2013–14, rates of services claimed by Indigenous Australians have doubled for GPMPs (from 55 to 114 per 1,000) and more than doubled for TCAs (from 44 to 96 per 1,000) with Indigenous rates in 2013–14 now higher than the non-Indigenous rates for both GPMPs and TCAs.

Source: Medical Benefits Division, Department of Health

Figure 3.18-3 Proportion of Indigenous regular clients with Type 2 diabetes who had a GPMP and TCA in the past 2 years, by remoteness areas, Indigenous primary health care organisations, December 2012, June 2013 and December 2013.
Indigenous regular clients with type 2 diabetes

Figure 3.18-3 shows the proportion of Indigenous regular clients (of Indigenous primary health care organisations) with type 2 diabetes who had a GPMP and TCA in the previous 2 years, by remoteness area for the periods December 2012, June 2013 and December 2013. Data are presented separately for GPMPs and TCAs. Upper/lower quartile boundaries and organisation medians are also presented. The data show that 47% of Indigenous regular clients with type 2 diabetes had a GPMP in the 2 years to December 2013 (an increase of 6 percentage points from December 2012) and 44% had a TCA (an increas of 7 percentage points from December 2012). Improvements were seen across most jurisdictions.

Source: AIHW, national Key Performance Indicators for Aboriginal and Torres Strait Islander primary health care data collection

Figure 3.18-4 Proportion of Indigenous regular clients with type 2 diabetes who had a GPMP and TCA in the last 2 years, by jurisdiction, Indigenous primary health care services, June 2012, December 2012, June 2013
Indigenous regular clients with type 2 diabetes

Figure 3.18-4 shows the proportion of Indigenous regular clients (of Indigenous primary health care organisations) with type 2 diabetes who had a GPMP and TCA in the previous 2 years, by jurisdiction for the periods December 2012, June 2013 and December 2013. Data are presented separately for GPMPs and TCAs. Upper/lower quartile boundaries and organisation medians are also presented. The data show that 47% of Indigenous regular clients with type 2 diabetes had a GPMP in the 2 years to December 2013. This was an increase of 6 percentage points from December 2012. In that period,

Source: AIHW, national Key Performance Indicators for Aboriginal and Torres Strait Islander primary health care data collection