Integrated Chronic Disease Management (ICDM) includes the following:
- planned and proactive care intended on keeping people as well as possible rather than responding to an illness
- empowering, systematic and coordinated care that includes regular screening, support for self management, assistance to make lifestyle and behaviour changes
- care that is provided by a range of health services and practitioners (eg. GPs, podiatrist, physiotherapist, counsellor, dietitian, nurse, specialist, dentist)
- care that is provided over time through the stages of disease progression
The Wagner Chronic Care Model, with its six interdependent elements, provides the framework for Primary Care Partnerships to develop a service system for improving the care of clients with chronic and complex care needs.