Chronic Disease Strategy
Rural and Remote
Learning objectives
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Be familiar with the Chronic Disease
Strategy in rural and remote settings
Understand the components of the
rural and remote model for chronic
disease
Be able to apply the model to daily
practice
What is it?
The Chronic Disease Strategy –
Rural and Remote is an
implementation of the QSCD.
It provides a holistic chronic
disease program in rural and
remote areas.
Chronic Disease Strategy
Rural and Remote
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Provides a framework for Service
development and delivery
Reorients the approach to chronic
disease
Supports comprehensive primary
health care and a systematic
approach to chronic disease care
Life Continuum
Age
0-4 yrs
5-14 yrs
15-54 yrs 55+ yrs
Immunisation
Prevention
Early
Detection
Health Promotion
Health
Check 0-4
Health
Check 514
Health
Check 1554
Health
Check 55+
Men’s and Women’s
Health
Hearing Health
Mental Health
Protocols & Care Plans-Recall & Referral
Management
Rehabilitation & Self Management
Effective Primary Health Care Information Systems – eg.
Ferret
Model for Rural and Remote
Areas
Levels of Intervention
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Domains or levels
of intervention and
Client and
community central
services
Clinical guidelines
Required to ensure
practice is
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standardised
evidence based
safe
Electronic support
Current system is Ferret
which is a
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Population register
Patient recall and
Decision support system
Provides care plans and
Population data and information
Quality improvement
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Required to monitor and
evaluate practice
Supported by clinical
indicators
Used to identify gaps and
support development of
services
Partnerships
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Collaborative approach
Government and non
government
Ownership at community
level
Supports sustainability
Workforce
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Workforce orientation and training
Chronic Disease Strategy Coordinators
Newsletters & training
Chronic Disease Guidelines
• Provides a summary of the
‘Chronic Disease QSCD’
• Integrates population health
approach
• Provides evidence based clinical
guidelines for:
•Health Checks
•Care plans
Learning Activity
Please complete the
learning activity