Queensland University of TechnologyCRICOS No. 00213JHLN004 Chronic conditionsprevention and managementChronic conditions management –frameworks, approaches and strategies
CRICOS No. 00213Ja university for the worldrealRWhat is chronic disease management?• Systematic, coordinated clinical managementprocess to improve healthcare for people with CD• Occurs across continuum of care– Includes treatment & education• Aims to improve quality of life & health outcomes &reduce progressions/ complications of CD– Maintains optimal functioning with most cost-effective& outcome-effective health care expenditure
CRICOS No. 00213Ja university for the worldrealRChronic Disease Management inAustralia• Reactive and acute focus one that is proactive andsupports the management of chronic disease across thedisease continuum– Includes the coordination of health care, pharmaceutical or socialinterventions– Designed to be cost effective and improve health outcomes• Systematic approach across levels (individual,organisational, local and national)
CRICOS No. 00213Ja university for the worldrealR• Delivery System Design– Create teams with a clear division of labour– Separated acute care from the planned care– Planned visits and follow up are important features• Self-management support– Collaboratively helping patients and families toacquire the skills and confidence to manage theircondition– Provide self management tools, referrals tocommunity resources and routinely assessingprogressElements of the CCM
CRICOS No. 00213Ja university for the worldrealR• Decision Support– Integration of evidence based clinical guidelines intopractice and reminder systems• Clinical Information Systems– Reminder system to improve compliance withguidelines, feedback on performance measures andregistries for planning the care for chronic diseasesElements of CCM
CRICOS No. 00213Ja university for the worldrealR• Community Resources– Linkages with hospitals providing patient educationclasses or home care agencies to provide case managers– Linkages with community based resources- exerciseprograms, self help groups and senior centres• Health Care Organisation– The structure, goals and values of the providerorganisation. Its relationship with purchaser, insurers andother providers underpins the modelElements of CCM
CRICOS No. 00213Ja university for the worldrealRModels for chronic disease management - InnovativeCare for Chronic Conditions (ICCC Framework)• Expansion of the Chronic Care Model• Provides roadmap for improvement of healthsystem’s capacity to manage chronic conditions• New expanded framework is comprised offundamental components within the levels ofpatient interactions, organisation of health care,community and policy.
CRICOS No. 00213Ja university for the worldrealRICCCThe organisation of health care systems and how theycontribute to CDM is discussed in terms of:• Macro Level– governments developing and implementing policies toprevent and manage chronic disease. Avoidfragmented financing of project and improvemonitoring and regulations• Meso Level– systems to manage care over time. This will includeeducation of health professionals, evidence basedguidelines, prevention strategies, information systemsand linking with community resources.• Micro level– individuals develop skills to prevent and manage theirown health
CRICOS No. 00213Ja university for the worldrealRWHO, 2002
CRICOS No. 00213Ja university for the worldrealRHow are Chronic Diseases ManagedAcross the world?From Zwar’s systematic review
CRICOS No. 00213Ja university for the worldrealRUSA• No national health care system• Series of health care providers operating in a marketbased system• Funded on 3 levels:- Government (Federal and State) funds Medicare for over65 years and Medicaid for low income earners- Employers through corporate membership of healthinsurance- Private individuals• Focus on acute services• Have adopted CCM• Poor primary health care system
CRICOS No. 00213Ja university for the worldrealRUSA• Access to health care is inequitable• Approx. 18% of population have no health insurance– Many with low income and have a higher prevalenceof chronic disease– unlikely that those individuals that have more thanone chronic disease have access to health insuranceand health care• Groups such as the Veterans Affairs and certainManaged Care organisations such as Evercare andKaiser Permanente have introduced interventionprograms based on CCM– All have had positive outcomes• USA still lags behind Europe in the management of CD
CRICOS No. 00213Ja university for the worldrealRCanada• Health Care is run by each province rather than anational system– Publicly funded system, free at point of use• CCM expanded to incorporate population healthpromotion to prevent chronic disease• Many of the expanded initiatives that have beendeveloped as part of the expanded CCM aresupported by the Primary Health Care Transitionfund• Vancouver Island Chronic Illness program designedto improve chronic care for the First Nation People
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CRICOS No. 00213Ja university for the worldrealRUnited Kingdom• The National Health Service is funded by thetax system, access is free• Strong focus on primary care– Rewards to GPs for good chronic care– National Service Improvement Frameworks foreach of the major chronic diseases
CRICOS No. 00213Ja university for the worldrealRUnited Kingdom• Primary care for chronic disease includesmanagement using guidelines and havespecialised clinics which are separate fromacute care services– National Institute for Health and Clinical Excellence(NICE) has produced disease specific guidelines -used as national standards of care• Practice nurses play a major role in chronicdisease management – assist GPs in reachingtarget goals
CRICOS No. 00213Ja university for the worldrealRNew Zealand• Care Plus – service for people with chronicdisease– delivered through Primary Health Organisations• Aim was to identify people with chronic diseasewho required intensive case management• Chronic care model has been developed inSouth Auckland.– Effective in improving patient outcomes for diabetes– Address inequalities in health and patient follow up
CRICOS No. 00213Ja university for the worldrealRChronic Disease Management inAustralia• Australia has developed its management of chronicdisease on the Chronic Care Model and the KaiserPermanente modelLevel 1: 70-80% of the chronic carepopulation can manage their own conditionLevel 2: High risk patients benefit frommultidisciplinary CDM using clinicalpathways and protocols with care planning,patient registries and shared electronichealth recordsLevel 3: Highly complex clients with co-morbidities or other factors greatly benefitfrom case management(National Health Priority Action Council, 2006, p. 4)Kaiser Permanente model
CRICOS No. 00213Ja university for the worldrealRChronic Disease ManagementPatients have chronic conditionunder reasonable control andreceive care through their primaryhealth care team– Priority - failure to improvethreatens population wideimprovements in chronicdisease prevalence andmanagementPatients have poorlycontrolled conditionsPatients with complex multidiagnoses,high use patients who receive casemanagement by registered nurses ormedical personnel
CRICOS No. 00213Ja university for the worldrealRNational strategic policy approach tochronic disease prevention & care• Two approaches1. National Chronic Disease Strategy– Overarching framework of national direction2. Five supporting National Service ImprovementFrameworks– Address key health priority areas– Asthma; cancer; diabetes; heart, stroke & vasculardisease; osteoarthritis, rheumatoid arthritis &osteoporosishttp://www.dhhs.tas.gov.au/__data/assets/pdf_file/0006/48390/Connecting_Care_Full_Version_web.pdf
CRICOS No. 00213Ja university for the worldrealRNational Healthcare Agreement (NHA) 2011• Provides for integrated approach to improvinghealth outcomes for Australians and thesustainability of the health system• Defines the objectives, outcomes, outputs andperformance measures, and clarifies the rolesand responsibilities that guide theCommonwealth and States and Territories indelivery of services across the health sector
CRICOS No. 00213Ja university for the worldrealRNational Health Care Agreement 2011/12• This National Healthcare Agreement affirms the agreement ofall governments that Australias health system should:– Be shaped around the health needs of individual patients,their families and communities;– Focus on the prevention of disease and injury and themaintenance of health, not simply the treatment of illness;– Support an integrated approach to the promotion ofhealthy lifestyles, prevention of illness and injury, anddiagnosis and treatment of illness across the continuum ofcare; and– Provide all Australians with timely access to quality healthservices based on their needs, not ability to pay,regardless of where they live in the country.
CRICOS No. 00213Ja university for the worldrealRObjectives of the HCA• Prevention– Australians are born and remain healthy• Primary Care and Community Health– Affordable and quality care• Hospital and related care• Aged care• Patient experience• Social inclusion and indigenous health• Sustainability
CRICOS No. 00213Ja university for the worldrealROutcomesandoutputmeasures
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CRICOS No. 00213Ja university for the worldrealRHealth Funding• The Australian Health Ministers Conference(AHMC) is the peak consultative body betweenCommonwealth and states/territories• Major health funding agreements are bilateralagreements between the Commonwealth andeach State and Territory– Strategic public health and other partnerships arenegotiated in similar ways.
CRICOS No. 00213Ja university for the worldrealRAustralian Health Care System• Universal access to health care via MedicareInsurance– Financed from general taxation revenue – 1.5%taxable income– Levy contributes ~27% of Medicare funding, so mustbe topped up with other taxes• Medicare provides for– Subsidised prescribed medicines, provided bydoctors, dentists and optometrists– Substantial grants to State and territory govts to runpublic hospitals
CRICOS No. 00213Ja university for the worldrealRHealth services deliveryAged care is structured around 2 main forms of care delivery1. Residential (accommodation and various levels ofnursing and/or personal care) – mainly non-govt sector– financed by Commonwealth and the places availableare also specified.2. Community care - provided jointly by Commonwealthand State to enable older people to remain in their ownhomes as long as possible– (delivered meals, home help, transport) – both publicand non-govt usually charitable or religious support
CRICOS No. 00213Ja university for the worldrealRPrivate Health Care• Private patients in private hospitals charged feesby doctors and some allied health staff• Billed for accommodation, nursing care andother hospital services such as operatingtheatres and radiology and pathology services• Private health insurance covers some/all costs– Some costs may be covered by Medicare
CRICOS No. 00213Ja university for the worldrealRHealth services delivery• Mix of public and private– quality is high• Large urban public hospitals provide most of themore complex type of hospital care – intensivecare, major surgery, organ transplant, renaldialysis and specialist outpatient services– Most acute care beds and emergency outpatientclinics are in public hospitals.
CRICOS No. 00213Ja university for the worldrealRAustralian Healthcare System
CRICOS No. 00213Ja university for the worldrealRThe Australian health system is a sophisticatedpublic-private and federal-state blendPublichospitalsPrivatehospitalsCONSUMERSOut of pocketAUSTRALIANGOVERNMENTSTATE /TERRITORYGOVERNMENTTaxes &levies(includingMedicareLevy)MBS PBS PHI rebatesCommunityhealthAmbulanceservices(some states)Aboriginal MedicalServicesResearchGPs&specialistsAlliedhealthPharm-acistsRural GrantsProgramsPublic healthprogramsTaxesandleviesPrivate health insurersPrivatelysuppliedgoodsandservicesKEYPayment by consumersPayment by govt and/orprivate sectorSource: Schematic courtesy of Australian Department of Health and Ageing Available at: http://www.australia2020.gov.au/topcis/docs/health/pptThis gives rise to a mixed model ofservice provision and accountabilities
CRICOS No. 00213Ja university for the worldrealRCurrent health funding remains overwhelmingly focused ontreatment1. Includes Commonwealth, State and local governments 2. Includes private health insurance funds, injury compensation insurers, and private individuals 3. Includes public andprivate hospitals and patient transportationSource: AIHW, National health expenditure 2005-6 (AIHW data cube)National health expenditure, by area of expenditure – Australia: 2005/6 ($ per capita)1,579Hospitals694Pharma-ceuticals,aids andappliances754MedicalservicesDentalservices148Other healthpractitioners315Capitalexpenditure/tax261Public andcommunityhealth121Admin93Research4,224TotalNon-governmentGovernment259Public/community healthrepresents just over 6% of totalexpenditure
CRICOS No. 00213Ja university for the worldrealRAustralia spends an average amount on health compared toother OECD countriesPer capita expenditure ($USD) (left hand axis)Health expenditure as % GDP (left hand axis)Health expenditure - OECD countries: 2004 (US$ per capita, % GDP)Source: OECD, Health Data 200701,0002,0003,0004,0005,0006,0007,00005101520KoreaHungaryCzechRepublicPortugalSpainNewZealandFinlandJapanItalyUnitedKingdomGreeceIrelandSwedenDenmarkNetherlandsMexicoCanadaGermanyFranceBelgiumIcelandAustriaSwitzerlandNorwayLuxembourgUnitedStatesTurkeyPolandGDP (%)Per capita (US$)SlovakRepublicAustralia
CRICOS No. 00213Ja university for the worldrealRHealth outcomes are significantly worse for low socio-economic groups, rural and indigenous communitiesLow socio-economic groups Rural and regional Australians Indigenous AustraliansBurden of disease,by SES quintile – Australia: 2003Burden of disease,by regionality – Australia: 2003Years of life lost (YLL)Years lost to disability (YLD)1. Disease Adjusted Life Years (years lost through death by disease, and years lost to disability by disease)Source: AIHW, The burden of disease and injury in Australia 2003 (2007); Vos, Barker et al, Burden of Disease and Injury in Indigenous Australians 2003 (University of Queensland,2007)Burden of disease, IndigenousAustralians by sex: 2003For more on Indigenous healthand disadvantage, see The Futureof Indigenous AustraliaFor more on social disadvantage, seeStrengthening Communities... (p11-15)050100150200250144Low142Mod.low140Aver-age124Mod.high115HighDALY per 1,000 population (years)1050100150200250127Major cities144Regional134RemoteDALY per 1,000 population (years)1050100150200250187Male217FemaleDALY per 1,000 population (years)1This is a disease burden2.5 times greater than anon-Indigenous populationof the same age profile
CRICOS No. 00213Ja university for the worldrealRLifestyle risk factors are also more prevalent in thesedisadvantaged sectors of societyLow socio-economic groups Rural and regional Australians Indigenous Australians1. Refers to Indigenous persons in non-remote areas, according to 2001 National Health Survey 2. Note that non-Indigenous statistics are age-adjusted, to represent estimate for a non-Indigenous population ofsimilar age/sex profile. Therefore figures for non-Indigenous population may not align exactly with absolute figures for overall population by SES or regionalitySource: ABS, 4364.0 National Health Survey: Summary of Results 2004-5 (2006); ABS, 4364.0 National Health Survey: Summary of Results 2001 (2002)Prevalence of selected health risk factors,top and bottom disadvantage quintiles2004-5Prevalence of selected health riskfactors, by regionality 2004-5Prevalence of selected health riskfactors, by Indigenous status 2001For more on social disadvantage, seeStrengthening Communities... (p11-15)For more on Indigenous health anddisadvantage, see The Future of IndigenousAustralia020406080100(% population)Bottom quintileTop quintileDailysmokingRiskyalcoholconsumptionSedentaryactivityOverweightorobese<1servefruit<4servesveg020406080100Outer regional/remoteMetropolitanInner regional(% population)DailysmokingRiskyalcoholconsumptionSedentaryactivityOverweightorobese<1servefruit<4servesveg020406080100Indigenous1Non-indigenous2(% population)DailysmokingRiskyalcoholconsumptionSedentaryactivityOverweightorobese<1servefruit<4servesveg
CRICOS No. 00213Ja university for the worldrealROuter regionalMajor cityInner regionalRemote/very remoteAccess to health services also varies significantlyacross communitiesAccess to health professionals varies widely As do the social barriers to health treatment1. Based on numbers of people employed, not FTE. 2. As at December quarter 2007 (PHIAC) 3. As at 2004 (ABS)Source: Most recent data on health practitioners provided by Federal Department of Health and Ageing; figures available on request. Private Health Insurance Administration Council (PHIAC), QuarterlyStatistics, December 2007; ABS, 1301.0 Year Book Australia 2006; ABS, 2068.0 Census Data 2006; AIHW, Male consultations in general practice in Australia 1999-2000 (2003); Klimidis et al, Mental HealthService Use by Ethnic Communities in Victoria, 1995-6 (VTPU, 1999)Private health insurance• 45% of Australians have private health insurance2• In addition to offering greater choice of healthprovider, these insurers help to cover the ~15% of hospitalservices with "gap" payments not covered by MedicareLabour force barriers• It is estimated ~25% of the working population is employedon a casual basis3• Where employment status does not include the right topaid sick leave, there may be an economic disincentive fortaking time out of work to seek medical treatment (over andabove the cost of treatment itself)Education and language barriers• ~15% of Australians speak a language other than English athome and ~3% of Australians speak English only poorly ornot at all• A Victorian study indicated that people who prefer to speaka language other than English are significantly under-represented in obtaining mental health services, bothcommunity-based and inpatientSocial stigma• A 1997 survey suggested that nearly 70% of people withmental health issues did not seek treatment – social stigmais thought to be a major contributor• A 2000 study found that almost 1 in 4 Australian men hadnot seen a GP in the previous 12 months (compared with 1in 10 women)For information on access toother services in rural andregional areas, see The Future ofRegional Australia (p7-8)7188121205475954 3852361132430189712801,0001,200200800Health practitioners per 100,000 population, by regionality: 2005-06 (# )1GPs Specialists Pharmacists Physio-therapists1,0091,090917736Nurses(all types)
CRICOS No. 00213Ja university for the worldrealRThe Australian medical workforce will face many challengesin meeting future demandThe medical workforce is growing,but GPs only just meet populationgrowthWe rely heavily on overseas-trained health professionalsOur future workforce will haveto flexibly meet community needsA strong base of national informationwill be central to effective workforce planning1. Refers to country of first qualification 2. This is an increase from 14% and 36% respectively in 2001Source: AIHW, Medical Labour Force 2005 (2008)% medical practitioners by place ofqualificationand citizenship status of overseasqualified, 2005Medical practitioners per 100,000population, Australia 1999-2005An increasing number of medicalpractitioners are working parttime, especially women• 15% of men and 38% of women workless than 35 hours per week2Many practitioners operate across multipleclinical settings• In 2005, practitioners worked in anaverage of 1.2 settings (private practice)or 1.3 settings (public practice)Recent reforms to the health workforce haveseen some roles and responsibilities expandto cope more flexibly with populationdemand• The introduction of Nurse Practitionersallows them to perform some dutiespreviously reserved for GPs e.g.prescribing medicine/ordering tests –particularly important in remote areas• Recent changes to the Medicareschedule allow longer GP consultationsfor managing mental illness/chronicdisease01002003001632001112 11120001641852005OtherpractitionersGPs20041801092003110Practitioners per 100,000 population (#)11120021721101999156 157109OverseasTrained121%AustralianTrained179%Citizen11%69%TemporaryResidentPermanentResidentResidenceStatus20%Ofwhich...
CRICOS No. 00213Ja university for the worldrealRSelf-ManagementAn integrated approach to electronic health record managementand information sharing has potential to help all players in thehealthcare sectorProvidersAdministratorsResearchersPolicy-makersFundersPatients• Fuller patient information (especially when patientis incapable of providing it) enables more informedand efficient clinical decisions, improved riskmanagement, and avoids unnecessaryprocedures/tests• Funders can connect immediately to providers tomake real-time coverage, approval and paymentdecisions• Administrators have better demand information tomake more efficient and effective use of resources• Policy-makers can gather better data to understandand manage demand, and to direct resourcestowards interventions which produce the mosteffectivehealth outcomes• Researchers may access more comprehensivedata, to more effectively analyse disease pathwaysand the effectiveness of interventions• Patients – particularly those with chronic diseases– can take more ownership of their own medicalinformation, assisting self-management. They cansimplify their interactions with payers/providersandreduce duplicationThere is opportunity to improve future productivity throughnew systems and approaches to careElectronic health infrastructureEvolving modes of care/clinical deliveryIn the context of chronic disease, communities, healthcarepractitioners and individuals will have increasingly interconnectedroles in the management of population health• Public screening/new vaccinations• Communitycampaigns toreduce lifestyle riskbehaviours• New approaches toeducation andreduction of riskfactors in children• New approachesto developinglong-termmanagementplans inconsultation withprimaryhealthcareproviders• Increasedpowers of non-acute carers tomanage chronicconditions• Greaterintegration ofallied andcommunityhealthprofessionals inongoing diseasemanagementMedicalTreatmentPrevention• New tools andhome-basedtechnologies forself-monitoring• Support forcarers inmanaging healthof disabledpersons
CRICOS No. 00213Ja university for the worldrealRSettings and Providers forChronic Care• Vast array of providers in a variety of settings• Important that integration and coordination ofcare occurs across all of these providers andsettings• Kaiser Permanente model majority of chronicdisease care required from community settings
CRICOS No. 00213Ja university for the worldrealRMedicare Items for managing chronicdisease(2010)
CRICOS No. 00213Ja university for the worldrealRThe item numbers and claimingfrequencyName ItemnoRecommended frequency MinimumclaimingperiodPreparation of a GPManagement Plan721 2 yearly 12 months*Preparation of Team CareArrangements723 2 yearly 12 months*Review of a GPManagement Plan732 6 monthly 3 months*Coordination of a Review ofTeam Care Arrangements732 6 monthly 3 months*Contribution to aMultidisciplinary Care Plan729 6 monthly 3 months*Contribution to aMultidisciplinary Care Planby an Aged Care Facility731 6 monthly 3 months**CDM services can be provided more frequently in ‘exceptional circumstances’.
CRICOS No. 00213Ja university for the worldrealRMBS Item 721 – GP ManagementPlan (GPMP)• For patients with a chronic (or terminal) medicalcondition.• Allow GPs to prepare care plans for eligible patientswhere the involvement of other health or care providersis not required.– Patient assessed, management goals agreed, patientactions identified, treatment and ongoingmanagement and documentation, review planned• Regular reviews every 6 months
CRICOS No. 00213Ja university for the worldrealRMBS Item 723 – Team CareArrangements (TCAs)• For patients with chronic or terminal medical conditionswho require ongoing care from a multidisciplinary team– GP determines eligibility• GP discusses/agrees with patient which providers shouldbe involved, what information can be shared, collaborateswith the participating providers, documents & sets reviewdate• Can be provided without a GPMP– To be eligible for Medicare rebates for the five individual alliedhealth services, a patient must be managed by a GP under both aGPMP and TCAs.
CRICOS No. 00213Ja university for the worldrealRMBS Item 729 – GP contribution tocare plans• For patients with a chronic medical condition havingmultidisciplinary care plan prepared or reviewed for themby another health or care provider.• GP confirms patient’s agreement for the GP to contribute tothe plan, collaborates with the person preparing/ reviewingthe plan, including the GP’s contribution in the patient’srecords– Eg. Hospital discharge planning
CRICOS No. 00213Ja university for the worldrealRMBS Item 731 – contribution to careplans for residents of aged care facilities• For GP to contribute to a multidisciplinary care plan for aresident of an aged care facility• Resident is eligible for Medicare rebates for up to fiveindividual allied health services and eight type 2 diabetesgroup items each calendar year
CRICOS No. 00213Ja university for the worldrealRAdvantages of CDM Items• GPs are able to choose between items for GPonly care planning or for team-assisted careplanning– Based on needs of patients• Enhanced role for practice nurses and AHWs• GPMP is widely accessible for patients withchronic or terminal conditions• Flexibility in claiming frequency• Enables GPs to contribute to care plansprepared for residents of aged care facilities
CRICOS No. 00213Ja university for the worldrealRFurther information• Key information is available at:– www.health.gov.au (follow the A-Z index and ‘C’ for‘Chronic Disease Management’)– www.health.gov.au/mbsprimarycareitems– Email inquiries: firstname.lastname@example.org
CRICOS No. 00213Ja university for the worldrealRChronic Disease ManagementWorkforce• Today’s healthcare workers need a core set ofcompetencies that will yield better outcomes forpatients with chronic conditions• A workforce for the 21st century must emphasisemanagement over cure and long term overepisodic care
CRICOS No. 00213Ja university for the worldrealRWHO’s Core CompetenciesWHO undertook a review in 2005 and listed thefollowing as core competencies for patients withchronic conditions:– Patient Centred Care– Partnering– Quality Improvement– Information and communication technology– Public health perspective
CRICOS No. 00213Ja university for the worldrealR1. Patient Centred Care• Interviewing and communicating effectively• Assisting changes in health related behaviours• Supporting self-management• Using a proactive approach2. Partnering• Partnering with patients• Partnering with other providers• Partnering with communities3. Quality Improvement• Measuring care delivery and outcomes• Learning and adapting change• Translating evidence into practice4. Information and communication technology• Designing and using patient registries• Using computer technologies• Communicating with partners5. Public Health Perspective• Providing population-based care• Systems thinking• Working across the care continuum• Working in primary health care-led systems(Pruitt and Epping-Jordan, 2005)Core Competencies as described by WHO
CRICOS No. 00213Ja university for the worldrealRSummaryNo correct approach to chronic disease managementTo be successful, policy makers should consider:- Providing strong leadership and vision at the national,regional or ogarnisational level- Ensuring robust collection of information and datasharing among all stakeholders- Providing care based on people’s needs and an ability toidentify people with different levels of need;- Targeting key risk factors, including widespread diseaseprevention initiatives- Supporting self-management and empowering peoplewith chronic diseases(WHO, 2008, p. 1)
CRICOS No. 00213Ja university for the worldrealRReferences• National Health Priority Action Council. (2006). National ChronicDisease Strategy. Australian Government Department of Health andAgeing, Canberra.• WHO(2008). A framework to monitor and evaluate implementation.• The Health of Queenslanders, 2010, 3rd report of the chief healthofficer, www.health.qld.gov.au/cho_report.• Pruitt, S. and Epping-Jordan, J. (2005). Preparing the 21st Centuryglobal healthcare workforce. British Medical Journal. 330. 637-640.• Zwar, N., Harris, M., Griffiths, R., Roland, M., Dennis, S., Davies, G.and Hasan, I. (2006). A systematic review of chronic diseasemanagement. Australian Primary Health Care Research Institute,Sydney.