Chronic Disease Management Program (CDMP)

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) provides a range of supports for 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”.

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.

CDMP program participants will be provided with intensive support  by a Care Coordinator who will assist with goal setting, addressing items outlined in GP care plans, and managing appointments. Program participants will also have access to funding to allow them to access specialists, allied health services, transport and equipment at no cost (to a limit).

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 Care Coordinator (registered/clinical nurse), to support and facilitate required services with each chronic disease patient.  In addition, the Care Coordinator  works with the client, their GP, specialist/s and other relevant providers to ensure an integrated approach is provided. The Care Coordinator 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.