Australian Better Health Initiatives (ABHI)
SESDGP's ABHI Project aims to develop and implement a system to better coordinate and integrate services for patients with certain chronic diseases and co-morbidities with a view to improving the self management of the specific conditions and therefore reducing the number of hospital admissions for these patients.
The system will be developed in consultation with patients, their GPs, other relevant service providers and relevant staff from Prince of Wales Hospital. The priority for the project will be a sustainable system that enables the development of evidence based shared care pathways that clearly delineate roles and responsibilities to the patient and relevant health service providers and provide better quality outcomes for the patient.
Objectives:
- Collaboration between primary and community care services.
- The use of electronic systems or communications applications to support integrated primary care.
- Uptake of MBS items that support integrated primary care services delivery for patients with chronic disease including those with complex needs.
- Better self-management by patients of their specific chronic disease in the community setting.
Activities:
- Identify specific chronic diseases to be the target of this project.
- Fostering and developing closer working relationships between general practice, hospitals allied health services and patients.
- Involving GPs in the development of procedures and strategies to ensure continuity of care of patients with chronic diseases and co-morbidities.
- Fostering, cultivating and encouraging fellowship, understanding and co-operation between service providers involved in the management of specific chronic diseases.
- Utilising tools/strategies that will assist in better managing patients with chronic diseases and co-morbidities.
- Contributing to the improvement and further development of local care pathways for specific chronic diseases.
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