Chronic Care Management

What is Chronic Care Management (CCM)?

The Chronic Care Model is a method of caring for people with chronic conditions, such as HIV.

It encourages practical and supportive chronic disease care and management based on evidence that shows us what works. The Model uses a proactive rather than responsive approach.

Being proactive means we focus on acting in advance to deal with an expected change or difficulty instead of waiting for something to happen and then responding or fixing things after the fact.

Chronic Care Management empowers people to take an active role in decisions around their health, goals, and other lifestyle choices. In addition, it acknowledges the challenging nature of navigating the health system with chronic or complex conditions.

Karumah uses the Chronic Care Model and Assessment of Chronic Illness Care (ACIC) developed by Ed Wagner et al. and MacColl Institute.

You can read more about the elements of the Chronic Care Model here.

What does the Karumah Case Manager do?

The Karumah Case Manager works directly with service users and undertakes a range of activities. These activities include assessments, goal setting, allied health referrals, assistance navigating systems like Centrelink or the NDIS, and mental health support.

The Karumah Case Manager recognises the importance of People Living With HIV taking an active role in managing their physical, mental and social health.

As with all Karumah services and activities, the Case Manager’s approach accommodates peoples’ knowledge of their lived experience. They work with our service users taking a non-judgmental, evidence-based approach that is flexible and adapts to the evolving needs of People Living with HIV.

Specifically, the Karumah Case Manager:

• Coordinates and provides care that is safe, timely, effective, efficient, equitable, and centred on service user needs
• Handles case referrals, drafts service plans, and reviews case progress
• Helps service users achieve wellness and autonomy, including assessing and addressing motivational and psychosocial issues
• Facilitates multiple care aspects (case coordination, information sharing, etc.)
• Helps service users make informed decisions by acting as their advocate regarding accessing services and benefits to which they are entitled, as well in clinical and other intervention settings.
• Develops effective working relations and cooperates with community, allied health and medical teams throughout the case management process
• Keeps confidential and accurate records about cases, completes necessary forms and produces required reports
• Promotes quality and cost-effective interventions and outcomes whilst adhering to professional standards as outlined by protocols, rules and regulations

Do I need a Karumah Case Manager and Chronic Care Management?

At Karumah, we know that many people living with chronic conditions such as HIV find managing their health and related issues a real challenge.

Karumah’s Chronic Care Management program helps people address these challenges. The program links people up with our Case Manager, who then works with them to create a personalised Chronic Care Management plan to address their specific needs.

We know these needs can span a wide range of areas. Some examples we often encounter include: helping decrease social isolation, assisting with interactions with social and government service agencies, and better-coordinating care between a service user’s pharmacy, doctors and allied health professionals.

The Karumah Case Manager provides service users with expert assistance with setting and meeting their health management goals.

How do I connect with the Karumah Case Manager?

If you would like to engage with any of Karumah’s services, please email admin@karumah.org.au or call 0411 060 154 to arrange a confidential conversation with our case manager.

Can I still be involved with Karumah if I don’t need Chronic Care Management?

Yes. Karumah works to provide

• Social and Community Support in the form of peer support and leadership, HIV community development and regular social events to help build connection and reduce social isolation
• Education and training opportunities that include workshops on life skills, sexual health and physical and mental wellbeing.
• Advocacy for individual level for People Living With HIV and for our community as a whole
• Karumah can also provide professional development for health and community service providers.

If you would like to engage with any of Karumah’s services, please email admin@karumah.org.au or call 02 4940 8393 to find out more.