This document discusses best practice primary health care for clients with chronic diseases. It describes the 2017 NACCHO Members Conference theme of "Our Health Counts: Yesterday, Today and Tomorrow". The document outlines Gurriny's model of care, which includes an Integrated Team Care program and engagement in health promotion. It also presents a case study of a client named Aunty J who accessed various chronic disease services including dietitians, diabetes educators, and medication reviews through the coordinated care provided by Gurriny.

1. 2017 NACCHO Members Conference
This year’s theme:
‘Our Health Counts: Yesterday, Today and Tomorrow’.
Best Practice Primary Health Care
for Clients with Chronic Disease
Suzanne Andrews
1

2. ‘Our Health Counts: Yesterday, Today and Tomorrow’.
Best Practice Primary Health Care
for Clients with Chronic Disease
2

3. Overview
• Engagement/Health Promotion
• Models of Primary Health Care
• Clinical and Service Delivery.
Our Health Counts: Yesterday, Today and Tomorrow’.
Best Practice Primary Health Care
for Clients with Chronic Disease
3

4. Engagement/Health Promotion
• Integrated Team Care (ITC)
• Formally Care Coordination &
Supplementary Services (CCSS)
• ITC team is made up of AHW’s & a RN (program is culturally
appropriate)
• Access to all the PHC & SEWB services at Gurriny
• Partnerships
Our Health Counts: Yesterday, Today and Tomorrow’.
Best Practice Primary Health Care
for Clients with Chronic Disease
4

5. Our Health Counts: Yesterday, Today and
Tomorrow’.
Best Practice Primary Health Care
for Clients with Chronic Disease
Models of Primary Health Care
Gurriny Model of Care
SEWB model of Care
5

6. Our Health Counts: Yesterday, Today and
Tomorrow’.
Best Practice Primary Health Care
for Clients with Chronic Disease
Gurriny’s Model of Care
6

7. Our Health Counts: Yesterday, Today and
Tomorrow’.
Best Practice Primary Health Care
for Clients with Chronic Disease
7

8. SEWB Model 2
Women’s
SEWB
programs
Youth
SEWB
programs
Health
Promotion
Grief and
Loss
Children
and Family
SEWB
programs
Men’s
SEWB
programs
Specialist
medical
services
Pharmacy
Child and
Maternal
Health
GP clinics
Sexual
Health
Chronic
Disease
Referral and Intake
Planning intervention
Engaging intervention
Monitoring
Evaluation
1Member of community can join SEWB programs
just as a member of the community. They do not
become a “client” at this point
2 People can come to the clinic solely to
see a medical/nursing/mental health
professional.
3 Patient has both physical and social
determinants impacting their health4 Person becomes a client. They need medical and a
more case managed approach to aid their well-being
Professional knowledges skills and
values drive a healing process
Bio-psycho social spiritual assessments
Bio-medical
worldview,
theory, skills
and values
Sociological, cultural
& spiritual
worldview, theory,
skills and values
First Nations people’s spirituality, worldview, knowledge, skills and values
Life
Promotion
Bringing
them Home
programs
8

9. Clinical and Service Delivery
Case study (Aunty J)
Our Health Counts: Yesterday, Today and
Tomorrow’.
Best Practice Primary Health Care
for Clients with Chronic Disease
9

10. Start - Access
Points
Calendar of Events
Staff, OHRW, CFC,
Reception
715
Health Check Allied Health
81300 * 5
RN/EEN/HP (on behalf of
GP provider number)
10987 * 10
Pit Stop Program
715 Health
Check
Mental Health Treatment Plan
2700 –2717
Yes-Register of PIP Chronic Disease
Identified
dentified
Mental Health Treatment Plan
Review
10 * Psychologist, Psychiatrist,
Occupational Therapist
ORHW/Wannabee/CF
C, SEWB, FSW
ECW
SEWB/FSW/ECW
DCC/ACC
Tier 1 GP Management
Plan/Treatment Care
Plan—721/723
Tier 2 Review
732 * 2
CCSS Home
Medication Review
> 5 med or 12 doses in
24 hours
Allied Health
10950 * 5
RN/EEN/HP (on behalf of GP
provider number)
10987 * 5
Exercise
Physiologist
81120
Group Therapy
Diabetes
Educator
81100
0
Dietician
81110
.
10

11. Our Health Counts: Yesterday, Today and
Tomorrow’.
Best Practice Primary Health Care
for Clients with Chronic Disease
Aunty J
Referral
to ITC
program
Dietician
Diabetes
Educator
Podiatrist
Occupational
therapist
Respiratory
Nurse
Exercise
Physiotherapist
Home
Medication
review
• Nephrology clinic for
management of CKD
11

12. Gurriny Model of Care
12
Our Health Counts: Yesterday, Today and
Tomorrow’.
Best Practice Primary Health Care
for Clients with Chronic Disease