Sustaining chronic disease management in primary care: Lessons from a demonstration project

Chronic disease self-management (CDSM) programs have been found effective in improving clinical, behavioural, and self-efficacy outcomes associated with a range of chronic illnesses, and evidence suggests that CDSM is effective in reducing health care costs and health service utilisation. As the setting where most chronic disease is managed, primary health care is an ideal setting for supporting CDSM. This study aimed to explore the uptake and sustainability of CDSM within routine activities of primary health care clinicians involved in the implementation of a demonstration project within an Area Health Service in Sydney NSW. Interviews and focus groups were conducted with managers and clinicians involved in the project. Findings included (1) widespread support from participants for CDSM (2) participating clinicians thought that CDSM was valuable to themselves, their clients and the health system (3) the program required clients to be able to speak and understand English and so presented many barriers for implementation in CALD communities, and (4) the program was not effective in engaging some key members of the primary care team; in particular, general practitioners. The study highlights system design issues including communication and continuity of care between service providers, workforce supply and demands of acute care delivery in the community that will need to be addressed for sustainable and effective CDSM to be achieved.