Chronic Disease Stories
The work that the practice team does in the Chronic Disease topic areas can make significant improvements to patient outcomes. Here, practices generously share their stories of change.
Click on the links to be taken to each practice's story.
Change Principal 1 - Building the practice team
Change Principal 2 - Establish a system for creating, validating, and updating a register of people with diabetes
Database tidying and data extraction
Acute cases management
Data cleansing
Change Principle 3 - Be systematic and proactive in managing care
The power of a registered nurse
CHD reminder system
Increase in annual diabetes checks
Tracking patient care
Change Principle 4 - Involve Patients in delivering and developing their care
Change Principle 5 - Develop effective links with key local partners
Change Principal 2 - Establish a system for creating, validating, and updating a register of people with diabetes
Database Tidying & Extraction
"I must say we did embrace the concept and greatly appreciated being led along the path of tidying our databases and being able to extract accurate informative data. We thought we were doing pretty well with our diabetics but our numbers showed room for improvement. We are now up to month 46 and still run our extraction every month and consider how we could be doing things better - as there is still room for improvement! The other important point to make would be the fact that it has engaged us as a team [clinical + admin] all working towards the same goal of improving our patients' health." Broughton Clinic, SA
Acute Cases Management
We have made lots of changes to update our Chronic Disease registers and to keep them accurate by correct coding. Whilst it can be difficult to instigate change we did manage to get everyone on board with this!
The flow on results have been standardising of care across the practice giving better patient outcomes and more timely performing/billing item numbers which keeps everyone at the practice happy!
We decided to have one GP responsible for acute cases and treatment room each morning. This has been without doubt the most positive change we have made. On a recent staff feedback survey, the receptionists stated it had made their life easier as urgent cases are seen promptly, patients are happy and less time is spent per phone call in triage/assessment. The nurses are happy as work flows more coherently in the Treatment Room with a Doctor on hand to review where required and GPs are happy as they know there won't be "fit ins" (at least for the morning session). Finally, principals are happy as the patients get to meet a range of GPs and are happier then to see different Dr if 'their' GP is fully booked." Chancellor Park Family Medical Practice, QLD.
Data cleansing
"In the last month, we have inactivated all patients who have not attended the surgery within the past two years. Furthermore, we have had to manually inactivate patients who weren't actually seen in the last two years, but whose files have been accessed for administrative purposes. This was necessary as administration was deemed a visit by the computer program. The process was tedious, but interesting. We found two deceased patients on the register!
Through these data cleansing processes, we have removed approximately 150 patients from our CHD and Diabetes Register. Now we have a more accurate and relevant register, and thus save resources in our recalls. This will also help us target our current patients, maintaining and improving our care for them. As new patients are added to the register, the framework is in place to provide high quality chronic disease management." Alpha Medical Centre, NSW.
Change Principle 3 - Be systematic and proactive in managing care
The power of a Registered Nurse
"The most significant has been employing a Registered Nurse to co-ordinate chronic disease management. In our Practice of six/seven doctors, the demands of clinical nursing were increasing rapidly. By using our Chronic Disease Management Nurse were able to rethink how we addressed our patients' needs, we had more time to look at being much more pro-active in seeking out patients who were at risk.
Our GP Division plagiarised the extraction tool developed for NPCC/APCC and modified it so we could firstly compare our data with local demographics in the form of the Health Atlas, and then we could de-encrypt our filtered data to obtain the identity of patients whom we could target for HMR's and GPMP's.
We continue to develop the Registered Nurse role and with the ongoing modification of the PENCAT extraction tool, we are able to refine searches of data, improve recording and cleaning up our system. With the ultimate aim of achieving ultimate patient care in ever widening circles, encompassing all forms of chronic disease." Mt Barker/ Balhannah Medical Clinic, SA.
To view this story as a 'virtual tabletop' and add comment see The rise and rise of the chronic care coordinator in the virtual tabletops pages.
CHD Reminder System
"We needed to find a reminder system for the doctors, when consulting patients who are on the CHD register (these patients are identified very easily, they are coded blue on the doctor’s appointment screen) to check that patients are up-to-date with recommended readings, levels and medications.
Importantly it also reminds the doctors to enter the data into the correct fields. We identified this as perhaps one of the issues which was affecting our percentages. We developed a screensaver so at the start of each day, when the doctors turned their computers on this would act as a reminder. We also ensured they had the desktop button installed on their taskbar so if they wanted to refer to the criteria it was a simple process, which did not involve having to close down their programs." Kyabram Regional Clinic, VIC.
Increased annual diabetes checks
"We at Woodside Surgery have increased the rate of annual diabetes checks from a low 12% in 2005 to 73% in 2009 by:
• Blocking out same day appointments to smooth the flow of patients generally, and aiding the task of doing Today's work today
• Sending reminder letters more boldly than ever before, with over 70% response
• Tic-tacking within the team (a cross between action research and PDSA) about how to make it all work ok.
• Being personable and being confident because we know what to do and why we do it - we have a plan.
• We keep a book of recalls due rather than use printouts it is 4 years since it started and still working well.
• We are about to use Pen Tool upgrade to replace our book and our trawling through billing records."
Woodside Surgery, SA.
Tracking GP Management Plans and Team Care Arrangements
The Doctors of Ivanhoe mapped out the steps involved in completing a GP Management Plan and Team Care Arrangments. They also produced a t
The Doctors of Ivanhoe tracking sheets are available from the links below:
- GPMP / TCA Tracking Sheet (pdf version)
- GPMP / TCA Tracking Sheet (spreadsheet xls version)
- DMMR Tracking Sheet (pdf)
Doctors of Ivanhoe, VIC.
To view this story as a 'virtual tabletop' and add comment see Tracking GP Management Plans and Team Care Arrangements in the virtual tabletops pages.