Count me in: Partnerships in chronic care
11th Annual National ADMA Conference 2015
10 - 11 September 2015
Brisbane Convention Centre, QLD
Conference Program 
(PDF File 2.2 MB)
NOTE: The information provided in the presentations below is not to be reproduced or used without the author's express permission.
Day 1: Plenary sessions
Opening session: Better outcomes for people with chronic and complex health conditions through primary health care (PDF File 265 KB)
Dr Steve Hambleton, Chair, Primary Health Care Advisory Group
Social networks, social media and social diseases (PDF File 2.5 MB)
Prof Enrico Coiera, Director, Centre for Health Informatics; Director, NHMRC Centre for Research Excellence in E-Health, Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, NSW
Improving chronic disease outcomes – what do we know that we know? (PDF File 2.3 MB)
Prof Brian Oldenburg, Chair, Noncommunicable Disease Control; Director, Centre for Health Equity, Melbourne School of Population & Global Health, The University of Melbourne, VIC
The Australasian College of Physicians and Integrated Care: A key partnership (PDF File 1.3 MB)
Assoc Prof Nick Buckmaster, Deputy Chair, Integrated Care Working Party, Australian College of Physicians; Medical Director of Internal Medicine, Gold Coast Hospital and Health Service, QLD
Engagement of stakeholders in system-wide primary healthcare improvement (PDF File 1.5 MB)
Prof Ross Bailie, Professor of Public Health, Scientific Director, Centre for Primary Health Care Systems, Menzies School of Health Research, NT
Indigenous health workers as chronic care coordinators: Benefits and challenges for health service managers (PDF File 1.1 MB)
Barbara Schmidt, Trial Manager, Getting Better at Chronic Disease Care Project, North Queensland project; Research Fellow, James Cook University, QLD
The AIMhi Stay Strong app (PDF File 2.3 MB)
Prof Tricia Nagel, Consultant Psychiatrist & Assoc Prof, Menzies School of Health Research, Mental Health, Wellbeing and Chronic Disease research division, Charles Darwin University, NT
The pointy end: Can we prevent hospital readmissions for chronic disease? (PDF File 1.7 MB)
Prof Alison Mudge, HMR Fellow and Physician, Internal Medicine and Aged Care, Metro North Hospital and Health Service, QLD
Interventions in chronic disease management: A review of the literature on the role of community pharmacists (PDF File 2.6 MB)
Prof Shu Chuen Li, Chair, Discipline of Pharmacy & Experimental Pharmacology, School of Biomedical Sciences & Pharmacy, Faculty of Medicine and Health, The University of Newcastle, NSW
Medication overload and deprescribing (PDF File 14 MB)
Prof Peter Pillans, Director, Clinical Pharmacology, Division of Medicine, Princess Alexandra Hospital, Metro South Health, QLD
Social marketing, social media and health (PDF File 3.5 MB)
Berni Murphy, Faculty of Health, School of Health & Social Development, Melbourne Burwood Campus, Deakin University, VIC
We’re in this together: Online social capital and social support for people with chronic illness (PDF File 884 KB)
Susan Stewart Loane, Department of Management and Marketing, Faculty of Business and Economics, Macquarie University, NSW
Lifestyle medicine: The big picture (not available)
Prof Gary Egger, Director, Centre for Health Promotion and Research, Sydney, NSW; Adj Professor, Lifestyle Medicine and Applied Health Promotion, Southern Cross University, NSW
Lifestyle medicine in clinical practice (not available)
A/Prof John Stevens, Adjunct School of Health and Human Sciences, Southern Cross University, NSW
Day 1: Concurrent sessions
ATSI Stream
Dr Deborah Askew, Southern QLD Centre of Excellence in Aboriginal & Torres Strait Islander Primary Health Care, QLD
A new model of care for a “Rapid hospital discharge service for newly diagnosed type 1 diabetes mellitus children” from the acute sector to a community service (PDF File 1.2 MB)
Robyn Mallett, North Lakes Diabetes Service, Community, Indigenous & Subacute Services, QLD
Aboriginal Chronic Care Program (PDF File 1.6 MB)
Libby Johns, Justice Health & Forensic Mental Health Network, NSW
Count me in: Engaging Aboriginal and Torres Strait Islander communities in chronic disease wellness programs on the Gold Coast (PDF File 882 KB)
Judith Murrells & Chris Buchanan, Chronic Disease Wellness Programs, Gold Coast Health, QLD; Menzies Health Institute Queensland, Griffith University and Nursing Research, Gold Coast Health, QLD
Ambulatory Care Stream
GP referrals to outpatient clinics: Observations on referral drivers and process in chronic disease management (PDF File 1.9 MB)
Lisa M Lee, Primary Market Research, Two Blind Mice, Sydney, NSW
Liz Lucas, Grand Pacific Health, NSW
Building an inter-professional practice system isn’t a choice, it is an imperative (PDF File 12 MB)
Claire Conlon, Intake and Inner North West Programs, Cohealth Community Health Service, VIC; Natasha Calesso, Mental Health Program, Cohealth Community Health Service, VIC
Evaluating wait time outcomes after implementation of the Osteoarthritis Hip and Knee Service (OAHKS) (PDF File 560 KB)
Bernarda Cavka, Physiotherapy Department, Royal Melbourne Hospital, VIC
Consumer Experience Stream
Participant experience focus groups: Engaging consumers in chronic disease management program redesign (PDF File 554 KB)
Marina Davis, Primary and Chronic Care Services, NSW Agency for Clinical Innovation (ACI), NSW
The Curse, the Castle and the Dragon (PDF File 2 MB)
Michael Gill, Founder Dragon Claw
What are people with severe mental illness saying about the work required to look after their physical health? (PDF File 330 KB)
Polly Chester, Centre of National Research on Disability and Rehabilitation, Menzies Health Institute, QLD; Griffith University, QLD
Telehealth-enabled self-care: Realising the aspiration (PDF File 290 KB)
Adj Prof Gary Morgan, 1 in 4 Lives Consortium, NSW; Science & Engineering Faculty, Queensland University of Technology, QLD
Peer Support & Self-Management Stream
Connect2: A motivational peer support model for people with type 2 diabetes (PDF File 1 MB)
Udani Abeypala, Diabetes Queensland, Milton, QLD
Innovation in patient education: A locally led partnership for integrated care (PDF File 956 KB)
Dr Tina Campbell, RealTime Health Pty Ltd; Linda Soars, South Eastern Sydney Local Health District, NSW
When is too late too late? Self-management capacity of our most complex patients - across the life course of disease (PDF File 1 MB)
Simone Jones, Integrated Chronic Disease Stream, Illawarra Shoalhaven Local Health District, NSW
A better question – the key to person-centred care and self-management (PDF File 1.4 MB)
Tina Dolphin, Better Questions are the Answer, VIC
Poster Stream 1
What does quality and safety mean in chronic disease management? (not available)
Dr Nancy Huang, Remedy Healthcare, Melbourne VIC
Counting the gain – improvements across the chronic care continuum (PDF File 831 KB)
Thomas Chapman, Integrated Care Unit, South Eastern Sydney Local Health District, NSW Health, NSW
Partnering with carers: enriching the relationship with people with long term conditions (PDF File 525 KB)
Linda Soars, Integrated Care Unit, South Eastern Sydney Local Health District, NSW Health
The sugar fix – partners in flipping our clinic (PDF File 478 KB)
Dan Shaw, Integrated Care Unit, South Eastern Sydney Local Health District, NSW Health
Heart failure services in Queensland: striving for better practice (PDF File 552 KB)
Annabel Hickey, The Prince Charles Hospital, Brisbane, QLD
CARING, Enabling, achieving together – that’s hip! (PDF File 437 KB)
Bernadette Mulcahy, Health Independence Program (HIP), Continuing Care Centre, Werribee Mercy Hospital, Melbourne, VIC
CAREFIRST: collaboration embedding quality research into everyday practice (PDF File 352 KB)
Rebecca Tinning, Medibank Private, Doctoral Candidate, School of Public Health and Community Medicine UNSW
A pilot study of a primary care based chronic disease management program for privately insured patients (PDF File 349 KB)
Rebecca Tinning, Medibank Private, Doctoral Candidate, School of Public Health & Community Medicine UNSW
Poster Stream 2
Chronic disease coordinated care model (PDF File 769 KB)
Natasha Carlesso, Chronic Disease Coordinated Care Model, cohealth, Melbourne, VIC
Capacity building to promote physical health in people with severe mental illness (PDF File 508 KB)
Anne Netherway, Carrington Health, Box Hill, Melbourne, VIC
Build it and they will come; developing a rural high risk foot service in Northern Victoria (PDF File 279 KB)
Toby Daff, Rural Allied Health Team & High Risk Foot Service, Goulburn Valley Health, Shepparton, VIC
Redcliffe Integrated Chronic Disease Model of Care (PDF File 140 KB)
Gordon Cox, Home Hospital Service, Medicine and Older Persons Services, Redcliffe Hospital Brisbane, QLD
Care journeys and care plans: community essentials! (PDF File 551 KB)
Leanne Carroll, Metro North Hospital and Health Service Community Transition Care, Brisbane, QLD
Listening to the voice of the people. Development of the Pilbara Aboriginal Heart Health Program: “Projects don’t work if they’re not what the community want” (PDF File 328 KB)
Lyn Dimer, Heart Foundation, Subiaco, WA
Paced (patient-centred and cardiac-nursing engaged device) service, an evaluation on its outcomes (PDF File 604 KB)
Yuen-Wa Leung, Division of Cardiology, United Christian Hospital, Hong Kong
The role of the palliative care nurse practitioner within the Hospital Admission Risk Program (HARP) in reducing unplanned hospital admissions (PDF File 386 KB)
Fiona McLeod, Hospital Admission Risk Program, Eastern Health, Melbourne, VIC
Poster Stream 3
Goal-setting as a mechanism for delivering patient-centred care by nurses in primary care (PDF File 261 KB)
Polly Chester, Centre of National Research on Disability & Rehabilitation, Menzies Health Institute, QLD; Griffith University, Meadowbrook, QLD
New complex chronic care evaluation tool (PDF File 220 KB)
Claudine Ford, Hunter Primary Care, Care Coordination program, Newcastle, NSW
Evaluating the quality and sustainability of the health coaching model of care from a patient and community nurse perspective (PDF File 493 KB)
Julie Curran & Nicky Holloway, Northern Sydney Home Nursing Service, Sydney, NSW
A melting pot of chronic disease? Manufactured Home Villages (PDF File 399 KB)
Karin Robinson, Grand Pacific Health, NSW
Unlocking the door to chronic disease management in custody (PDF File 738 KB)
Sharon Jacobs, Justice Health & Forensic Mental Health Network, NSW
Evolution of the chronic/ complex care nurse coordination role, within a home nursing service 2010 – 2015 (unavailable)
Susan Law & Jo Lange, Chronic & Complex Care Coordinators, North Sydney Home Nursing Service, Northern Sydney Local Health District, NSW
Aligning chronic disease staff goal setting practices with best practice guidelines (PDF File 378 KB)
Chris Vonier, Cabrini Health, Melbourne, VIC
Bridging the gap in care transition from the tertiary hospital to general practitioners (PDF File 437 KB)
Elian Chia, Chronic Disease Management Office, Singapore Health Services Pte Ltd, Singapore
Poster Stream 4
Benefits of smoking cessation programs within chronic disease population (PDF File 122 KB)
Simon Shah, Chronic Disease Wellness Program, Gold Coast Health, Gold Coast, QLD
Development and evaluation of an online comprehensive lifestyle change intervention for common risk factor reduction in the prevention and management of type 2 diabetes, metabolic syndrome and cardiovascular disease (unavailable)
Stephen Penman, National Institute of Complementary Medicine, University of Western Sydney, NSW
Guiding patients and staff down the smoking cessation clinical pathway (PDF File 341 KB)
Deepali Gupta, Smoking Cessation Clinical Pathway Project Team, Metro South Hospital & Health Service, Brisbane; Pharmacy, Princess Alexandra Hospital, Metro South Hospital & Health Service; Pharmacy, QEII Jubilee Hospital, Metro South Hospital & Health Service, Brisbane, QLD
The Chronic Disease Oral Health Pilot Project (PDF File 391 KB)
Shazia Huq, Oral Health Service, Royal North Shore Hospital, NSLHD, Sydney, NSW
Partnering with consumers and GPS using clinical indicators for self-management (PDF File 512 KB)
Jane Judd, Partnering with Diabetes Consumers, Alexandra District Health, VIC
Building the evidence for integrated care for adults with type 2 diabetes: A pilot study (PDF File 262 KB)
Jessica Browne, The Australian Centre for Behavioural Research in Diabetes, Diabetes Australia-Vic; School of Psychology, Deakin University, Burwood, VIC
Engaging with culturally and linguistically diverse (CALD) communities in delivery of chronic disease prevention and self-management (PDF File 157 KB)
Paul Tomane, Ethnic Communities Council of Queensland (ECCQ), West End, QLD
WWW.HEARTONLINE.ORG.AU: A toolkit for cardiovascular medication management (PDF File 868 KB)
Serena Rofail, Heart Failure Service, Royal Brisbane & Women’s Hospital, QLD; School of Pharmacy, University of Queensland, Brisbane, QLD
Day 2: Breakfast session
A contemporary health management partnership - tackling complex care needs in the West Moreton community (unavailable)
Ms Sharon Kelly, Director, West Moreton Hospital and Health Service, QLD
Day 2: Supplementary session
Patient Centred Integrated Care at scale – the Gold Coast Experiment (PDF File 1 MB)
Prof Martin Connor, Executive Director of the Centre for Health Innovation, Griffith University and the Gold Coast Hospital & Health Service, QLD
Day 2: Plenary sessions
Challenges and opportunities in implementing integrated diabetes care in Asia (PDF File 3.5 MB)
Prof Juliana Chan, Chair Professor, Department of Medicine and Therapeutics; Director, Hong Kong Institute of Diabetes and Obesity; Director, Clinical Research Management Office; Co-director, CUHK-PWH International Diabetes Federation Centre of Education; Chief Executive Officer, Asia Diabetes Foundation; The Chinese University of Hong Kong
Integrated whole-person chronic care: Views from the Canadian system (PDF File 2 MB)
Conj Prof Jean-Frederic Levesque, Chief Executive, Bureau of Health Information, and Conjoint Professor, Centre for Primary Health Care and Equity, University of New South Wales; Strategic Analytic Advisory Committee, Canadian Institute of Health Information
Technology enablers in chronic care (PDF File 1.6 MB)
Dr David Doolan, Chief Health Information Officer, Telstra Health
Health literacy – building effective partnerships & engagement between consumers and healthcare providers – Ophelia study (late cancellation)
Adj Assoc Prof Jeannine Jacobson, Manager HACC and Assessment, Ageing and Aged Care Branch, Mental Health, Wellbeing, Social Capital and Ageing, Department of Health & Human Services, VIC; Adj Assoc Professor, School of Health and Social Development, Faculty of Health, Deakin University, VIC
Shared medical appointments (PDF File 1.8 MB)
Prof Garry Egger, Director, Centre for Health Promotion and Research, Sydney, NSW; Adj Professor, Lifestyle Medicine and Applied Health Promotion, Southern Cross University, NSW
Improving access and equity in reducing chronic and preventative health risks (PDF File 1.3 MB)
Victoria Chalmers, Director, Health Contact Centre, Community and Scientific Support, Health Support Queensland, Department of Health, QLD
Moving health investment upstream (PDF File 2.6 MB)
Dr Kevin Cheng, Head of Integrated Care, Medibank Private
Establishing the new Primary Health Networks (PDF File 1.2 MB)
Sharon Appleyard, Assistant Secretary, Primary Health Networks Establishment’s Branch, Commonwealth Department of Health, ACT
Day 2: Concurrent sessions
Health Payers Stream
Evaluating disease management interventions – have we reached a ceiling? (PDF File 3 MB)
Dr Nancy Huang, Remedy Healthcare, VIC
Long-term impact of a chronic disease management program on hospital utilisation and costs in an Australian population with heart disease or diabetes (PDF File 455 KB)
Gerrye Stegall, Healthways Australia
Counting the benefits – disease management program evaluation for health insurers (PDF File 110 MB)
Bronwyn Hardy, Actuarial Services, Teachers Federation Health, NSW
Prevention & Self-Management Stream
Chronic disease prevention in Australia: Enhancing accountability (PDF File 986 KB)
Prof Maximilian de Courten, Centre for Chronic Disease, Victoria University, VIC
DESMOND: A diabetes self-management program and its potential to decrease or delay the onset of complications associated with diabetes and other chronic illnesses (PDF File 982 KB)
Sue Stockdale, Diabetes-WA, Perth, WA
Dr Amanda McGuire, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD
Improving Care Stream
An innovative integrated model of care and development of a registry for diabetes in the Hunter New England Region (PDF File 2.2 MB)
Dr Annalise Philcox, Department of General Medicine, Calvary Mater Hospital, Newcastle, NSW
Stephen Penman, National Institute of Complementary Medicine, University of Western Sydney, NSW
Improving care delivery and quality of life amongst people with Parkinson’s (PWP) in residential facilities (RF) following staff educational curriculum (PDF File 2.7 MB)
Margarita Makoutonina, ParkiLife Australia Pty Ltd, VIC
Multidisciplinary Stream
Improving care for people with chronic conditions and their carers: How can community pharmacy help? (PDF File 882 KB)
Sara S McMillan, Menzies Health Institute Queensland, Griffith University, QLD
Increasing access to physiotherapy in an ambulatory setting: The impossible challenge? (PDF File 533 KB)
Sarah Fitzhenry, Caloundra Hospital, Sunshine Coast Health Service District, Queensland Health, QLD
ONTRACK after the cardiac blues: Translational research in action (PDF File 1.7 MB)
Assoc Prof Rosemary Higgins, Heart Research Centre, VIC; Deakin University, VIC; The University of Melbourne, VIC;
Cabrini Health, Malvern, VIC