Implement strategies to prevent and provide better care for chronic conditions
Providing a comprehensive response to the significant burden of illness and correspondingly increasing efforts toward early intervention and prevention will require a whole-of-system alignment, including greater clarity of roles and responsibilities of all providers supporting individual patients and their families.
Develop a region-wide and whole of system plan for prevention and management of chronic disease, in partnership with the Hospital and Health Services and Queensland Aboriginal and Islander Health Council.
Focus on mental health (including child and youth), drug and alcohol use, CVD, diabetes, kidney disease and COPD.
Key components of the plan will include:
- Healthy lifestyles and behaviours
- Regular health checks
- Earlier detection and intervention
- Risk stratification to identify and target people with high needs, including those with complex co-morbidities
- Scheduled care initiated by the GP, and documented in a care plan
- Linking primary health care effectively with specialist services
- Shared health records, patient registers and care plans
- Culturally informed practice
- Improved linkages with social care