Chronic
Conditions
At Katherine West Health Board, the Preventable Chronic Disease Strategy was developed to address five main chronic diseases - Type 2 diabetes,
Hypertension, Heart disease, Kidney disease and Chronic airways disease.
Intervention aimed at reducing or changing risk factors is important, as these diseases are related to each other through their underlying causes.
Program Coordinator:
Position Vacant
Katherine Office | P: 08 8971 9300 | M: N/A | E: N/A
Program Literature:
Chronic Conditions – An Overview
The goal is to minimise or reduce the consequences of chronic disease and prevent or delay potential complications through effective management for the client, such as good glycaemic control in diabetics and self-management programs for clients living with a chronic disease.
The chronic disease program has the following elements:
The focus of the Preventable Chronic Disease Strategy is to reduce chronic disease incidence, early diagnosis of new cases and best practice management of cases.
In 2009 and 2010
Chronic Conditions and Self Management
Routine clinical audits reveal that KWHB staff have continued to achieve excellent results in the clinical management of chronic conditions. This has provided the framework to strengthen the move from an acute care focus to a chronic care model where health behaviours of clients are instrumental to improving health outcomes. A primary aim over the last year in the care of clients with chronic conditions was to increase awareness of strategies around changing health behaviours.
To support this, significant work was undertaken to develop Communicare templates for SNAPE, involving specific questions in the areas of Social, Nutritional, Alcohol, Physical Activity, and Emotional Wellbeing, which provide staff with a springboard for brief interventions, a technique for health promotion which is becoming more embedded in everyday clinical practice.
Brief Interventions
KWHB continued to strive for a shift in emphasis from acute care to health promotion and chronic disease prevention at the health centre level, and an important strategy to achieve this was to introduce ‘brief interventions’ into everyday practice of all PHC Staff.The incorporation of brief interventions into everyday practice has grown considerably. An extensive amount of staff training has gone into this area. Also developing clinician’s skills in motivational interviewing when speaking with clients has changed the way in which topics such as alcohol and other drugs is discussed and also how we generate interest in topics with clients. It is empowering clients to make positive choices in their lives with support from health professionals.
Introduction of SNAPE
A supportive strategy that has been successfully implemented has been to integrate SNAPE (Smoking, Nutrition, Alcohol, Physical Activity, and Emotional health) into Katherine West Health Boards patient information recall system. The KWHB SNAPE tool, adapted from the RACGP SNAP Framework and the National Guidelines for smoking, nutrition and alcohol is a now incorporated into the patient information recall templates. These templates now prompt and guide the clinician to ask the client about risk factors and assess the clients’ stage of behavioural change using the stages of change health theory. Clinicians then advise the client on aspects of the risk factor and assist the client with strategies to achieve cessation or reduction. Finally arranging follow up with the client occurs. The SNAPE tool is being utilised by all KWHB clinicians however outcomes such as how many clients have successfully quit smoking are yet to be evaluated.
There are challenges in the delivery of the low intensity SNAPE program. The program has to be entirely delivered through the local health centres, but the frequent turnover of staff and their limited knowledge on behavioural theories of health, along with the significant inhibitors of self management in remote communities, may result in minimal impact on clients’ behaviour change. Assisting clients with behavioural change is challenging with the limited strategies available. KWHB is providing ongoing education on the behavioural health theory to all staff as a strategy to overcome the effects of frequent turnover.
Better health promotion resources
Health literacy is a foundation to successful self management of KWHB’s clients with chronic conditions. Therefore another strategy has been to support clients’ self management of their health by improving health literacy with the use of consistent messages and resources throughout the region. Numerous health promotion resources were developed by the Health Promotion Coordinator and Alcohol and Other Drugs Coordinator and approved for use by the Ngumpin Reference Group, for example:
• a core set of approved health promotion resources has been established on the staff intranet suitable for clinicians to use in both one-to-one consultations and more public activities
• health promotion materials were produced as part of the oral health promotion strategy – including a set of 5 oral health posters for use in community meetings and community education.
KWHB believes that changing health behaviours and improving health literacy within the KWHB region is a key to improved health outcomes with the development of self management for chronic conditions.
Chronic Disease Collaboratives
The direction of the Chronic Disease Collaboratives (a rapid quality improvement approach) is largely determined by issues identified from clinical auditing and systems assessment workshops. Topics are identified, and Plan, Do, Study, Act cycles are prepared weekly in accordance with priorities and evidence based practice of chronic disease. The Plan, Do, Study, Act cycles are placed on the intranet where staff can access at all times for reference. The introduction of the KWHB Health Promotion Policy along with the review of chronic disease resources by the Health Promotion Coordinator has allowed a consistent approach for staff when conducting chronic disease checks or arranging health promotion activities in relation to chronic disease. The Health Centre Coordinators encourage participation and follow up action in the chronic disease Collaboratives.
Engaging the community in self management of health
Health promotion was better planned, run and evaluated this year and much was achieved due to strong support from program coordinators, good planning and hard work from clinic staff on the ground. Katherine West Health Board staff were involved in a number of diverse health promotion activities and programs in 2008/2009. Apart from the education provided during health centre consultations, a variety of programs and partnerships meant that most communities in the Katherine West Region were exposed to or involved in some health promotion.
In the spirit of integrated PHC, health promotion was driven by health centres with support on the ground from other KWHB staff - not just PHC program coordinators but also administrative and operational support staff.
Several ‘”one off” health promotion activities or contributions to community events were also organized in the Katherine West Communities. The activities at these events were not part of the overall health promotion program but are valuable in two ways: firstly because they have been recognized previously by the community and health centre as a successful method of engaging community members in health education, and secondly through the opportunity they provide for the health service to be involved and recognized as supporting positive community events and the health centre’s role in the community.