Prevention and Management of Long Term Conditions

Description and Aims

This stream is a response to the challenge of long-term conditions to health and health care services.   These conditions include diabetes, cardiovascular disease, asthma and chronic obstructive lung disease, cancer and mental illness.  They commonly occur as multi-morbidities.   The aim is conduct research in the community which informs improvement in health care and programs which aim to prevent and manage these conditions.

Key Current Research Areas

Prevention

The program focuses on improving interventions to address the behavioural risk factors (especially Smoking, Nutrition, Alcohol and Physical activity) as well as physiological risk factors such as obesity and cardiovascular risk in primary health care.  This uses the 5As framework (ask/assess, advise, agree and assist, arrange), approaches tailored to health literacy levels and use of wearable technology and social media.

Management

This program focuses on a patient centred approach based on the Chronic Care model and includes teamwork, information and communication systems (including e-health), self-management support and community resources.  This is the focus of work on diabetes, cardiovascular disease, asthma, COPD, cancer, mental illness and multi-morbidity.

Key Partners

This research is conducted in partnership with primary health networks and local health districts along with other groups including Aboriginal Health organisations.

Stream lead

Mark Harris leads the stream. 

Current
Projects

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Supporting newly arrived migrant mothers in Canterbury from Bangladesh and China

Culturally and linguistically diverse migrant mothers are more likely to experience lower levels of access to health care. This project, funded by Healthdirect Australia and conducted in Sydney Local Health District, aims to increase equity of access to information and health care for non-English speaking migrant mothers.

AMPACe – Accelerometers for Monitoring Physical Activity in Primary Care

AMPACe aims to assess the feasibility and any benefit of integrating accelerometer or activity tracker use in primary care as means of promoting physical activity. It follows on from a smaller 2016 pilot study.

Clinical Pathways: Multidisciplinary shared care plans (Clozapine shared e-care planning)

This project is evaluating the feasibility of an online shared care plan supporting communication between GPs, specialist services, consumers, carers and other care team members  for clozapine treatment,  preventive care and behavioural change in the long-term shared management of people with a lived experience of severe mental illness. The care plan sets out the tasks required, when they need to be completed and who is  responsible. This intervention is being implemented with the My GP & Me shared care program currently running in the SESLHD, Eastern Suburbs Mental Health Service.

The project is one of 4 clinical pathways projects funded by Mindgardens Neuroscience Network.

 

Development of risk profiling matrix for chronic diseases and preventive smartphone application

This project aims to promote healthy ageing through a smartphone app-based intervention, specifically, by helping people prevent the onset of cardiovascular disease and type 2 diabetes mellitus.  

Electronic shared care plan for long term care of cancer patients

A feasibility study to develop and determine how best to engage GPs and patients in a cancer shared e-care plan and assess how specialists, GPs and patients use the e-care planA feasibility study to develop and determine how best to engage GPs and patients in a cancer shared e-care plan and assess how specialists, GPs and patients use the e-care plan

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Completed
Projects

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A cluster randomised controlled trial of nurse and general practitioner partnership for care of COPD

A cluster randomised controlled trial of nurse and general practitioner partnership for care of COPD

Determination of the impact of nurse and GP partnership on the quality of care and health outcomes for patients with COPD at six months and twelve months follow-up

A pilot study in managing Anxiety and Stress in Cross-Cultural Encounters among Chinese-Australians (Beyondblue community grant in collaboration with Chinese Australian Services Society)

This project involved the delivery of ‘Assertive Communication Skills’ to help Chinese-Australians manage their stress and anxiety in cross-cultural encounters in everyday settings. This project also sought to bridge the cultural gap by equipping participants with culturally appropriate skills.

A project to assess the effectiveness and feasibility of case finding of Chronic Obstructive Pulmonary Disease (COPD) by practice nurses in General Practice

This project investigated the prevalence of COPD diagnosis in an Australian general practice setting, and whether an intervention utilising practice nurses addresses under-diagnosis of COPD.

Absolute risk assessment in general practice – a pilot study to measure impact on prescribing and adherence to guidelines

Prevention of cardiovascular disease (CVD) is a priority for the Australian community and general practitioners (GPs) play a key role in this activity. This study aims to test the impact of ARA in general practice on prescribing of anti-hypertensive and lipid-lowering medications and adherence to guidelines.

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PhD
Projects

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Advance Care Planning in Australian Primary Care

This study explores the key stakeholders, general practitioners and patients' views on how Advance Care Planning is currently conceptualised and implemented.

Development of risk profiling matrix for chronic diseases and preventive smartphone application

This project aims to promote healthy ageing through a smartphone app-based intervention, specifically, by helping people prevent the onset of cardiovascular disease and type 2 diabetes mellitus.