Introduction
Purpose
The Latrobe community is engaged and invested in the health and wellbeing of its people. Significant events over recent years have impacted the health and social outcomes of the community, however, there remains a determination and desire to improve the health experience for individuals, in particular those with chronic disease.
Local health services together with community representatives in Latrobe have worked together to develop this action plan. The plan itself seeks to bring people together to take action on areas that will improve the experience of chronic disease in Latrobe over the next five years (2022-2027). It builds on existing successes and considers new ways of working when needed.
The plan itself is one component of work being undertaken across Latrobe. Initiatives in other sectors (e.g. education, transport and social services) will be delivered in parallel, and also aspire to improve health and wellbeing outcomes for the Latrobe community.
The Vision
To understand the vision for the Action Plan, we invited key stakeholders across Latrobe to tell us what the future of Latrobe should be like for people with chronic disease.
The vision of the 2022-2027 Chronic Disease Action Plan is:
To create an inclusive and integrated service network for all people with chronic disease. The voice of the individual or carer is heard, and they can access what they need at the right time to live a healthy and fulfilling life in Latrobe
Terminology
In this Action Plan, the term ‘chronic disease’ is used. This is in line with the Australian Institute of Health and Welfare (AIHW) National Strategic Framework 20171, which acknowledges the use of the terms ‘chronic conditions’, ‘non-communicable diseases’ and ‘chronic diseases’ as a broad range of chronic and complex health conditions across the spectrum of illness, including mental illness, trauma, disability and genetic disorders. This broad definition is intended to move the focus away from a disease-specific approach and is adopted as a definition for this Action Plan1.
The terms ‘person’, ‘people’, ‘consumers’ or ‘individual’ are used to refer to people at risk of developing/or with one or more chronic diseases. Providers of services are referred to as ‘practitioners’ to encompass all disciplines, specialties and clinicians from all types of services. ‘Latrobe’ refers to the Victorian local government area of Latrobe City on which this action plan is focused.
Audience and role of the Action Plan
The Action Plan provides a roadmap for the Latrobe community, stakeholder organisations, private providers, industry and groups that advocate and offer care and education for people with chronic disease and their carers and families. The plan offers both achievable and ambitious actions to drive improvements in Latrobe.
Living with chronic disease in Latrobe
Steps have been taken to improve the experience of living with chronic disease in Latrobe, but there is more to be done. The proportion of people with chronic disease is above the Victorian state average. This creates challenges for the local service system where demand exceeds the available support.
Many factors are currently contributing to the over -representation of chronic disease.
They occur across three levels:
Individual
People living in Latrobe are typically older and the prevalence of risk factors for chronic disease, including behaviours that are commonly associated with chronic diseases, impact the communities’ health and wellbeing. These include smoking tobacco, eating a poor diet and physical inactivity. Supporting people with or at risk of developing chronic disease is extremely important for their health in the long term.
Community
A healthy community is supported by access to health care, recreation opportunities, transportation, family and environments that encourage people to live healthy lives. These factors enable individuals to understand, engage and use services that will support their health in the long term in Latrobe.
Service
Health service availability in Latrobe is a known challenge due to a range of physical access and capacity issues within the local area. Specialist medical services, in particular, have significant waiting periods and, for many people, the metropolitan and/or private services they may be offered are not accessible. Enabling collective impact across the health system in Latrobe is key in improving the experience for the community.
Across all three levels there is a complex interplay between the social determinants of health such as education, economic stability, housing, and job security. While some actions in this document will address these indirectly, there is widespread commitment in Latrobe to improve the social determinants through a range of initiatives.
A snapshot of chronic disease in Latrobe
33.5%
of people in Latrobe are living with two or more chronic diseases
26
general practices across the Local Government Area of Latrobe City
For every 100 people in Latrobe
26
experience very high disadvantage which significantly impacts their health and wellbeing
1,212
Potentially preventable hospitalisations in one year in Latrobe
1 in 4
people in Latrobe is aged 65 years or older
Aboriginal people are
Twice
as likely to have a hospital admission or emergency department presentation than a non-Aboriginal person in Latrobe
Taking coordinated action in Latrobe
This Action Plan complements existing work from federal, state and local governments, as well as local health and other services, where chronic disease is a priority.
Locally, the 2014 Hazelwood Mine Fire Inquiry 9 initiated work to develop improved coordination pathways for people with chronic disease in Latrobe. Since that time, other key milestones have included the establishment of the Latrobe Health Innovation Zone in 2016, community consultations on chronic disease (2018-2019) 10 and the 2020 Listening to Latrobe Report 11.
To build on this work, the Latrobe Chronic Disease Action Plan has been designed to promote a coordinated, whole-of-system approach to bring the relevant stakeholders and initiatives together.
This Action Plan considers and seeks to align with policies and plans at a local, state and national level including:
- Australian Health Ministers Advisory Council- National Strategic Framework for Chronic Conditions 20171
- Central West Gippsland Primary Care Partnership- Creative Community Consultation Workshops in Chronic Illness 2019
- Latrobe City Council- Latrobe City Council Disability Action Plan 2018-2021
- Latrobe City Council- Living Well Latrobe- Our community’s Municipal Public Health and Wellbeing Plan 2022-2025
- Latrobe Community Health Service - Focused on the Future - Strategic Plan 2022-2027
- Latrobe Health Advocate- Improving access to services in Latrobe 2021
- Latrobe Health Advocate- Engagement Inspiration from People Living with Chronic Conditions in Latrobe 2020
- Latrobe Health Assembly- Strategic Plan 2020-2025
- Latrobe Regional Hospital - Strategic Plan 2020-2024 Latrobe Regional Hospital
- PHN Gippsland- Gippsland PHN Priorities 2022-25
- PHN Gippsland- Latrobe Chronic Disease Workforce Consultation Report February 2020
- The Victorian public health and wellbeing plan 2019-2023
Developing the Plan
The Action Plan has been developed together with key stakeholders representing consumers and carers as well as health and community services within Latrobe. It has sought to validate the ongoing relevance of the Listening to Latrobe 11 themes since the onset of the COVID-19 pandemic, and to confirm priority areas for focus in the Action Plan.
Between June and August 2022, stakeholders were engaged in a series of consultations, community forums and workshops to collaboratively design the Latrobe Chronic Disease Action Plan.
The design of the Action Plan occurred with the support of both community and practitioner representatives. The time and input by workshop participants is acknowledged and has enabled a robust and consumer-centred approach to be applied to the development process.
Together with the Latrobe Health Assembly (LHA), the Gippsland PHN (Gippsland PHN), Latrobe Community Health Service (LCHS) and Latrobe Regional Hospital (LRH) have taken a leading role in endorsing this plan, and collectively committing to implementation.
Furthermore, this plan has been endorsed by local people, professionals and leaders across the health system in Latrobe.
The Latrobe Health Assembly and its partners acknowledge Aboriginal people as the traditional custodians of the land on which we operate. We commit to working respectfully to honour their ongoing cultural and spiritual connections to this country.
Chronic disease continuum of care
The Action Plan has been structured around the chronic disease continuum of care. The plan recognises that responses to chronic disease can be conceptualised as a continuum through different levels of treatment and care. Throughout their life, a person may move between phases and require different supports to meet their needs.
With initiatives underway in the prevention and promotion space, as well as existing investment in the acute phase of care, the middle three stages of the continuum were the identified priorities for coordinated action in this plan. The Action Plan will therefore seek to enhance the early detection and identification, self-management and community-based treatment and care phases of the chronic disease continuum of care.
Action Plan principles and structure
The principles focus this Action Plan on what matters. The principles were collaboratively designed with key stakeholders across the region and assisted in highlighting Latrobe’s strengths and priorities for the next five years. They were used to shape the actions detailed in the Action Plan, encouraging achievable and ambitious activity for chronic disease in Latrobe. These principles should be front of mind for the implementation of the Action Plan itself.
The principles focus this Action Plan on what matters. The principles were collaboratively designed with key stakeholders across the region and assisted in highlighting Latrobe’s strengths and priorities for the next five years. They were used to shape the actions detailed in the Action Plan, encouraging achievable and ambitious activity for chronic disease in Latrobe. These principles should be front of mind for the implementation of the Action Plan itself.
Consumer at the centre
Ensure the consumer’s voice is at the heart of the work
Latrobe focussed
Prioritise local solutions where possible
Sustainable and feasible
Seek to create change that can be sustained and evaluated for progress
Accessibility
Enable service access at the right time, in the right place, with the right people
Education and communication
Share information in a meaningful way to empower and connect
Innovation
Continuously improve and remain open to new ideas, opportunities and technologies
Partnerships and collaboration
Codesign and share solutions to achieve the same goals
Integration and continuity of care
Establish seamless connection across and between services
Action Plan
1. Early detection and intervention
Early detection and intervention identifies people at risk of developing, and those in the early stages of, chronic disease. This is achieved by ensuring people are aware of risk factors, participate in screening, and establish connections to early intervention programs and services.
Early detection and intervention identifies people at risk of developing, and those in the early stages of, chronic disease. This is achieved by ensuring people are aware of risk factors, participate in screening, and establish connections to early intervention programs and services.
2. Self-management
Self-management is a process through which people have the confidence and skills to navigate the medical, social and emotional challenges of chronic disease in their daily lives.
2.1 Improve access to groups and facilities that support self-management
A key component of effective self-management is connecting the individual with groups and facilities that can improve health outcomes, such as public exercise facilities and community support groups. Activities within this action area seek to create a more accessible system and empowering individual choice.
2.2 Enable carers/family members to support individuals with chronic disease at a level of involvement appropriate for them
This area focuses on providing opportunities to better understand the ways carers can offer support throughout the chronic disease care continuum. These activities seek to promote the role of carers, while ensuring their level of involvement is appropriate for them and the people for whom they offer care.
2.3 Increase services at consumer-centred times and locations
Accessibility of services is an ongoing consideration within Latrobe. Activities in this area seek to build on existing work to understand opportunities to expand the provision of out-of-business-hours services. It also intends to embed a transparent approach to scheduling and communication about waiting times for services.
3. Community-based treatment and care
Community-based treatment and care involves multidisciplinary services providing active and ongoing support for people to live their everyday lives, partnering with them to improve health outcomes.
To optimise experience and outcomes, community-based treatment and care should meet the social, physical and mental health needs of the individual. Communication and partnership between the individual, their carers and family members, and the multiple involved provider agencies is critical to success. These agencies can include allied health professionals, general practitioners (GPs), medical specialists, and support workers.
3.1 Enable delivery of culturally and psychologically safe services
To ensure services within Latrobe are truly accessible for all people, this action area has a focus on driving cultural and psychologically safe services and practices. Activities in this area seek to upskill and empower capability to deliver safe and appropriate responses to care.
3.2 Improve continuity of care for community-based services
Individuals participating in community-based treatment and care often have multiple providers involved over extended periods of time. These activities focus on improving a sense of ongoing connection to create a clearer, more integrated and seamless care experience.
3.3 Optimise the use of technology to deliver care
Technology has a role to play across the care continuum, however activities have been focused within the community-based treatment and care phase as they will be driven by practitioners. They seek to build technology uptake and literacy to support care delivery, ultimately improving individual access and experience of care.
Moving forward
Ongoing work across practitioners and community is needed to support implementation of this Action Plan.
Ensuring success
To ensure this Action Plan achieves its goals, a range of supports (enablers) will be required to increase the chances of successful implementation. These supports have been identified by the people and services within Latrobe and are universal across the whole Action Plan.
Workforce
Strategic partnerships
Effective communication
Communicating updates
Keeping Latrobe updated on the progress of this Action Plan will be completed by LHA. This will include direct feedback to consultation groups, online bulletins and communications by the action owners.