Chronic illnesses are highly prevalent conditions with incidence rates that are increasing. The main health problems in Australia are chronic in nature. The main chronic conditions that are National Health Priorities include diabetes, cardiovascular disease, mental health problems, cancer, and asthma. There are high hospitalisation rates for acute complications associated with these conditions. Prevention of these complications is the most cost effective strategy for health care systems.

Information technology

The use of internet-enabled clinical and administrative systems supports methods of care that are oriented towards prevention and the promotion of health. Efficient patient assessment, case management, monitoring and information workflow between health professionals improves the efficiency of care. Internet technology also provides a form of interactive media for educating patients.

There is a significant emphasis on the integration between clinical approaches and information technology. Internet-based clinical systems contain treatment planning protocols to assist clinicians with decision-making. These aspects of treatment are evaluated at process, impact and outcome level to maintain and develop the quality of service delivery.

Clinical approach

Our approach involves directly targeting acute events and the longer-term management of chronic conditions. It focuses on reducing the risk of future episodes of illness and complication. There is an emphasis on the use of patient-centric strategies to manage the illness over time. Treatment approaches target critical social factors in the patient’s life and health. Psycho-education, therapy and self-management education maximises the benefits of each approach of the disease management model. We also assist patients and their families to make use of treatment technology.

Therapy is primarily based on cognitive-behavioural models with an emphasis on those which promote self-management and health behavioural issues such as attitudes and beliefs. In all cases, the aim is to achieve illness remission for the patient, mimimise impairment and disability and to optimise quality of life.

The treatment team workplace will support peer education and participation to enhance development of programs and the delivery of therapy.

Demonstrate primary health care

The clinic model will demonstrate that primary health care is a cost-effective model for the delivery of services. Reorientation of certain clinical processes is an essential strategy to demonstrate the effectiveness of internet-based assessment and monitoring as well as self-management health promotion. Without the reorientation of services, there is a lack of support for patients, which ensures the use of and adherence to programs.

Case management

Case management occurs to some extent in the community, however, the information systems are not in place to facilitate an effective process. Service reorientation is important in order to support case management. An adapted nursing role provides the case management service to patients. This position also has the responsibility of coordinating workflow between other clinicians who are responsible for the patient.

Assessment

• Obtain enough preliminary assessment information to determine if further assessment is required..
• Shape expectations: - If we assess further what information we provide that builds the expectations of what we do and what we will deliver?
• Effective and efficient assessment examining biological, psychological and social aspects of each individual.
• Obtain sufficient information to provide a foundation to construct an effective treatment plan.

The clinical management process

• This process commences when there is a preliminary enquiry to Sentiens.
• If the patient may benefit from the services the assessment system commences using PsychAssess.
• The patient is prospectively provided with information on the service via the Case Management System.
• The patient is assessed and triaged in or out of the service.
• If triaged into the service decisions are made as to the type of service, clinicians to be involved and a level of case management.
• Treatment commences and the patient is managed through the process by an internal case manager.

Models of treatment

Treatment plan based upon dealing with:

• Biological factors such as genetic inheritance and vulnerability, how medication effects the person, concurrent physical disorder, previous response to treatment
• Psychological factors- level of emotional response, personality, habits, motivation, patterns of problem solving, strengths, weaknesses, insight, defences, approach to dealing with disorder, acceptance of disorder
• Social factors including supports, family, relationship patterns work, financial situation