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.
Completed
Projects
TCRN Cancer Project
Cancer patients, their cancer specialists and GPs were interviewed about expanding the role of GPs in the long term care of patients with cancer. This identified the need for a shared care plan between the hospital specialist services and GPs.
Team-link study: AHMAC outcomes of multidisciplinary care in general practice
This study explores whether improvements in teamwork between general practitioners and referral services lead to improved patient outcomes.
Teamwork: Enhancing the role of non GP staff in Chronic Disease Management in General Practice
The aim of this study is to examine the extent to which quality of care for patients with cardiovascular disease and diabetes can be increased through a structured intervention involving practice managers, receptionists and nurses.
Telephone coaching models to support chronic disease management in multi-morbid and vulnerable populations: a rapid review (Sax Institute)
This rapid systematic review was commissioned by NSW Ministry of Health, working with the Sax Institute. The review will inform thinking about a possible state wide telephone coaching service for people who are, or at risk of becoming, high users of the hospital system for the management of their chronic conditions.
The collaborative care planning scale: A new measure of shared decision making in chronic illness care
This study will use standard psychometric techniques to ensure that the CCPS is a reliable and valid scale for use in studies of interventions to improve the health outcomes of people with chronic and complex illnesses.
