About

Aim of the Program

NCACCH has expanded its Brokerage model to include a support program for Aboriginal and/or Torres Strait Islander clients living with a chronic condition/s. The Chronic Disease Management Program (CDMP) triages referrals with a focus on clients who have been diagnosed with cardiovascular, diabetes, chronic respiratory diseases, cancer, chronic renal conditions and severe sleep apnoea. (Other chronic conditions can be included, however the conditions above will be prioritized).

CDMP Funding

The CDMP program receives two lines of funding from;   “Central Queensland, Wide Bay, Sunshine Coast PHN” and “Queensland Health”. The current contract for both funding sources is current until June 2018 (subject to funding).

Purpose of the Program

To provide support to Aboriginal and/or Torres Strait Islander clients living with a chronic condition. With the aim of self-management, it assists clients to manage their medical care to improve their health and quality of life in a significant way.

With a focus on goal setting, improving compliance with care plan obligations and appointment attendance, the participant will be provided with intensive support over a three (3) month period (can be extended for complex cases) by a Care Coordinator.  Furthermore, the client will be assisted with access to specialists, allied health services, transport and equipment at no cost (to a limit).

When the client has reached self-management status, they are invited to attend a six week self-management program. The content focuses on strategies and information to support long term self-management behaviour. This program was developed through Anglicare and facilitated by accredited NCACCH staff.

The Service Delivery Model & Scope

CDMP is the NCACCH chronic disease and health management program to facilitate and support efficient and effective management of multiple care strategies for clients with chronic disease health needs. The model combines three major strategies –

  • Provision of no cost, local access to Specialist/Allied Health services
  • Self-management support
  • Population health data collection

NCACCH has expanded its NCACCH brokerage and fee support model for the provision of access to required support services for its chronic disease clients. NCACCH negotiates with approved health services to bulk bill and/or invoice NCACCH and provide relevant reporting for consultations. If applicable, NCACCH then pays for the service on behalf of the client. This will ensure the client receives access to services at no cost to them.

A key strategy of CDMP is the provision of “Self-Management Support” (SMS). The program provides the expanded scope of a Health Advocate (registered/clinical nurse), to support and facilitate required services with each chronic disease patient.  In addition, the Health Advocate works with the client, their GP, specialist/s and other relevant providers to ensure an integrated approach is provided. The Health Advocate’s role is crucial , as they work closely and consistently with the client to provide the best outcomes possible. Health Advocates can act as a communication link between various care providers and assist the client to access required services/pathways for services such as in-home support, community programs, diagnostics etc.

 

CDMP Brochure

Download the brochure if you would like quick reference to the overview of the program. If you would like hard copies of the brochure, please use the “contact us” option or phone NCACCH on 5346 9800 and we will be...

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CDMP Shared Provider Roles

The following provides an overview of the shared provider roles. This  is a guide only, and directly relates to clients participating in the NCACCH Chronic Disease Management Program (CDMP). CDMP Client Flowsheet Feb17 CDMP Care Coordinator Role Feb2017 CDMP General...

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Program Flowchart

The program flowchart is provided to Health Advocates and is a simple step by step guide of the program outline from commencement. In addition, it incorporates the process for clients who cannot be contacted or disengaged. CDMP FlowChart Feb17

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NCACCH Head Office

8/8 Innovation Parkway BIRTINYA Queensland 4575

Phone: 07 5346 9800 | Fax: 07 5346 9899