Personalised care, health coaching for chronic disease patients in Whittlesea, Monash and Banyule

17 August, 2017

People in Whittlesea, Monash and Banyule newly-diagnosed with chronic conditions will be able to better manage their health through a partnership between Eastern Melbourne PHN (EMPHN) and Medibank.

The EMPHN funding will build capacity at 15 general practices in the region to manage chronic disease and will deliver the CareFirst program to more than 700 public patients living with a chronic disease.  Patients will be selected by their General Practitioner (GP) to participate in the program and will be provided with a personalised care plan and health coaching to help them improve their quality of life and stay out of hospital.

Delivered by Medibank, CareFirst is a six-month evidence-based behaviour change program for people recently diagnosed with chronic heart failure, chronic obstructive pulmonary disease, osteoarthritis, type 2 diabetes or cardiovascular disease.

EMPHN CEO Robin Whyte said the program also supports general practice to provide a team-based model of care within communities that have some of the highest rates of chronic disease in EMPHN’s catchment.

“Management of chronic disease in primary care is complex and requires working in partnership with a team of health professionals,” Ms Whyte said.

“The funding will improve the capability and confidence of GP teams to support residents in the Whittlesea, Banyule and Monash areas to manage their health through planned rather than reactive care.”

Medibank General Manager of Member Health Rebecca Bell said she was pleased to see CareFirst delivered in the region.

“Chronic disease is one of the biggest health challenges facing Australia today, and we look forward to working with GPs to help these communities live healthier lives,” Ms Bell said.

“CareFirst has had some great results for people living with chronic conditions, including significant improvements in their blood pressure, level of physical activity, waist circumference and, most of all, their quality of life, and a decrease in risk of hospitalisation.”

Principal GP at Whittlesea Family Medical Centre Dr Hannah Perfecto, said the program will build the capacity of GP clinics such as her own to better manage chronic disease which is prevalent in the local community.

“Whittlesea has higher rates of chronic diseases such as type 2 diabetes and cardiovascular disease than the state average, so being able to better support these patients and provide a personalised care and behaviour change program will help reduce the severity of such diseases in our community.”

An open market tender process was undertaken for the project. Medibank was appointed based on their experience implementing evidenced based programs to positively modify behaviour of patients with chronic disease and its ability to develop the capacity and capability of primary care providers to better manage chronic disease. The program will be independently evaluated by Australian Healthcare Associates to assess its success in improving the participants’ health status and risk of future hospitalisations.

The program is supported by funding from the Commonwealth Government under the PHN Program.