The Queensland Strategy for Chronic Disease 2005 -2015  is a statewide strategy that aims to engage all stakeholders involved in the prevention, intervention and management of chronic diseases at a system, service and individual level across the continuum of care.

It identifies evidence based approaches to prevent or reduce behavioural and lifestyle risk factors, and support better care for people with chronic disease and their carers/families.

The strategy aims to address barriers to quality chronic disease care, address the current pressure on the acute hospital system by reducing avoidable hospitalisations, and identify more systematic and sustainable approaches to the prevention and management of chronic disease across Queensland.

Two Chronic Disease Coordinator positions have been established within GPQ to support the implementation of the Strategy across the divisions. Through these positions, GPQ engages with the Queensland Aboriginal and Islander Health Council (QAIHC); Ethnic Communities Council Queensland (ECCQ); and Combined Health Agencies Group (CHAG) as a collaborative Non-Government Chronic Disease Leadership Team (NGCDLT).

• Key Focus Areas
• Achievements
• Resources

For further information, please contact Jann Offer, Team Leader joffer@gpqld.com.au

Key Focus Areas

The GPQ Statement of Strategic Intent 2007 - 2011 has identified four goals:

1. To be the key voice on primary health care in Queensland
2. Drive change in primary health care
3. Maximise investment in primary health care
4. Deliver a high performing and valued portfolio of services

The work of the Chronic Disease Coordinators is guided by the outcomes from a mapping and consultation exercise and informed by the recommendations from the Health Summit - Chronic Disease (2008).

Collaborative feedback from across the primary health care sector, presented in Chronic Disease - A Call to Action, highlighted the need to focus on:

1. Advancing a whole of population approach in preventing chronic disease
2. Enhancing system elements - Embedding Self Management
3. Enhancing system elements - Building Workforce Capacity
4. Providing effective systems for Coordinated Care

Achievements

Since 2010 the following have been achieved;

• Circulation of the fortnightly Population Health Update e-newsletter to division staff and external key stakeholders
• Refinement of The Map located on the GPQ website which provides a profile of chronic disease activity occurring across the Queensland Divisions Network, in collaboration with key stakeholders. All stakeholders have access to this information to enhance sharing of project goals, evaluation processes and outcomes. The Map:
  - provides ready access to resources, promotes information sharing and has the potential to reduce duplication of activities;
  - informs strategic partners about the breadth of work occurring enabling identification and promotion of new opportunities; and
  - will soon have new programs added such as mental health.
  
• Progression (in partnership with QH) of the Brief Intervention Project Workshops to encourage uptake of brief interventions by general practice and QH staff
• Hosted the Chronic Disease: Strength to Strength Workshop in June at which division projects relating to primary care integration and self-management were showcased
• Participated in the March 2010 Queensland Divisions Forum focusing at the program level on health literacy
• Hosted a booth with other members of Non-government Chronic Disease Leadership Team (NGCDLT) at the Queensland Health Chronic Disease Forum in May to promote the work of the Team
• Supported representatives on a number of Queensland Health Statewide Clinical Networks including the Statewide Diabetes, Renal, Cardiac and Respiratory Networks. This facilitated advocacy for engagement with general practice to achieve best practice care across the continuum
• Provided representation on the Queensland Public Health Forum (QPHF) where GPQ is contributing to the development of the ‘Eat Well’ Resources
• Ongoing work in partnership with QAIHC to align strategies to respond to the Council of Australian Governments (COAG) Closing the Gap initiative
• A member of the team became a Master Trainer for the Flinders Self Management Program - this will enhance health professional access to training in Queensland
• Advanced the development of a Position Statement for ‘The role of the Queensland Divisions Network in Self Management’
  

Resources

• Type 2 Diabetes Standard Care Pathway Project: GPQ Final Report 2008-2010
• National Chronic Disease Strategy
• Queensland Strategy for Chronic Disease 2005-2015
• Framework for self management 2008 - 2015
• Advancing Health Action – Making Queenslanders Australia’s Healthiest People 2008
• The Health of Queenslanders 2008
• AHIW Australia’s Health 2008
• Health Determinants Queensland 2004
• RACGP SNAP Guidelines: a population health guide to behavioural risk factors in general practice  
• RACGP Guidelines for Preventative Activities in General Practice – The Red Book 
• RACGP Putting Prevention into Practice – The Green Book  
  
• The Department of Health & Ageing: Resources and latest developments on Chronic Disease Management
• Centre for GP Integration Studies: The Centre conducts research, evaluation and development programs on integration of care in primary care.
• Australian Primary Care Collaboratives (APCC): APCC aims to find better ways to provide primary health care services to patients through shared learning, peer support, training, education and support systems and is funded by the DoHA.
• HealthInsite
• Rural Chronic Disease Initiative
• Diabetes Australia
• Good Life Club (Health Professionals)
  
• National Heart Foundation
• The Cancer Council Queensland – Prevention 
• USA, Department of Health and Human Services, National Centre for Chronic Disease Prevention and Health Promotion, Chronic Disease Prevention