Improving the management of chronic medical conditions through functional modelling

Background
An integrated primary care approach is beneficial for the management of chronic medical conditions such as diabetes. Due to the complexity of managing such conditions, however, particularly in a low socioeconomic and culturally diverse community, the approach needs to be contextualised.

Aim
Understanding the expectations of the community through a systems perspective to improve the management of chronic medical conditions with an integrated care approach.

Approach
We held six focus groups, including 35 people living with and/or caring for someone living with a chronic disease, residing in a low socioeconomic and culturally diverse urban region in Australia. We also interviewed 16 clinicians and experts from the local Primary Health Network. From the thematic analysis, we built a functional model of how integrated care might be delivered. We identified five key activities involved in the management of chronic conditions and how they relate to one another, modelling the coherence of the functional model. Needs from each activity were identified, as well as barriers and facilitators, and suggestions were made as to how to meet these needs. Subsequently, we developed a set of recommendations.

Outcomes
Recommendations included weaving links between medical and social services, including non-profit organisations within the region, co-designing a space within an integrated care centre for community non-clinical activities and matching culturally patients and clinicians. Managing chronic medical conditions is a team endeavour and requires a collaborative mindset and participatory leadership.