Chronic conditions are the leading contributor to the burden of disease in NSW.
This increasing burden of disease across NSW is exaggerated in the Far West Local Health District (FWLHD) due to the relationship between chronic disease risk factors and multiple demographic characteristics including:
- an ageing population of residents, with those 65 or older representing 22% of the population compared to 16% across NSW
- increased risk-taking behaviour (drug and alcohol)
- fragmented service provision and patient journeys between acute and primary care settings.
Changing the way we monitor chronic disease
In 2015, a 12-month pilot began in Broken Hill to test the effectiveness of remote monitoring for chronic disease management. The pilot provided:
- a remote monitoring kit to measure biometics at home
- a tablet device to collect observations and securely upload data into an Integrated Care Platform (ICP)
- monitoring by dedicated clinicians (including intervention and escalation as needed).
To support this program, the Western NSW Primary Health Network facilitated collaboration between FWLHD, the Broken Hill GP Super Clinic and Maari Ma Health. FWLHD continues to strengthen this engagement as patients from each practice complete the program.
Following the successful pilot, this program has been adopted as an ongoing model of care delivered by the Integrated Care for People with Chronic Conditions (ICPCC) team in collaboration with local General Practitioners (GPs).
Putting consumers in the front seat
The FWLHD In-home Monitoring Program addresses an increasing burden of chronic disease by remotely monitoring people in their own homes and building capacity to self-manage.
The program now covers over 100,000 km² of remote NSW. In a 2017 patient satisfaction survey, the program achieved a net promoter score of 100%, with patients highlighting access to clinicians, supportive technology and improved self-dependence as useful aspects of the program.
Several benefits of the program were identified, including:
- consumer increased confidence to self-manage health conditions immediately after discharge
- increased continuity of care, with the GP remaining the main care giver and responsible for the care plan
- reduction of emergency department admissions through early intervention and prevention.