Queensland's Chronic Conditions Manual - supporting rural and remote health

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Chronic conditions make the largest contribution to premature death in western societies. It is estimated that in the next 20 years the burden of chronic conditions will account for 80% of Australia’s ill health and represent more than 70% of all health care expenditure, straining national health infrastructure and valuable resources.

Having access to concise nationally accepted management guidelines to address chronic conditions - especially for our most vulnerable First Nations people - in a clear, consistent and evidence-based manner, is a vital part of the patient's journey to a healthier life. Since 2006 the Chronic Conditions Manual - Prevention and Management of Chronic Conditions in Rural and Remote Australia has met this need. 

The Chronic Conditions Manual is a collection of guidelines developed using contemporary, evidenced literature and best practice frameworks, with use by clinicians as a core aim. In particular the Manual aims to support Queensland’s rural and remote doctors, nurses, allied health and Aboriginal and Torres Strait Islander Health Workers.

How it works

The Manual’s contents, in four key sections, are accessed according to the patient’s presentation. 
 
If the patient would like general healthy lifestyle info the Clinician will access Section 1. Lifestyle modifications. This section contains best-practice healthy lifestyle information that aims to support clinical practice. These are: 

  • Engaging our patients
  • Alcohol reduction
  • Diet and nutrition
  • Physical activity
  • Sexual and reproductive health
  • Smoking cessation. 

This information can be copied and disseminated to patients to support healthy lifestyle behaviours.

Likewise, all patients should be offered an opportunistic Health Check to screen for chronic conditions at recommended intervals throughout their lives. 

The Section 2. Child health check and Section 3. Adult health check provides best-practice recommendations for routine checks from birth to old age to identify chronic conditions. It provides a systematic guide for performing health check assessments via direct questioning and clinical procedures, and recommends referral if concerns are identified . Health check sections focus on health promotion and are complemented by both the Lifestyle modification and Management of diagnosed conditions sections of the manual 

If, on the other hand, a patient with a known chronic conditions presents to a clinic, Section 4. Management of diagnosed conditions is the standardised tool to use. This section is intended for all clinicians who work directly with patients with a chronic condition. It provides 26 separate guides for the most common chronic conditions in rural and remote Australia. These guides follow the same format and include the following: 

  • The introductory box – highlights high risk groups, consideration for women of child-bearing age if appropriate, and the need for urgent referral 
  • What is – provides a brief background and explanation of the condition 
  • Diagnosis – briefly outlines elements taken into consideration when diagnosing the condition
  • Management – details the specific elements required to successfully manage the condition including strategies around patient engagement and continuity of care 
  • Medications –  provides options on various treatment modalities considered appropriate for the condition, including a list of suggested LAM and PBS approved medications 
  • Cycle of care – provides a structured care pathway for the clinician to monitor progress and assist with follow-up and ongoing management 
  • References – each guide has its own reference section listing the relevant information sources 
  • Resources – offers the clinician examples of up to date on-line resources to provide further information to assist with managing and educating patients. The clinician is encouraged to also seek additional local resources as required 

 The Chronic Conditions Manual is currently being digitised, with the aim of having a preliminary version, including an app, by the end of 2021. 
 

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