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Chronic Disease Management
Good chronic disease management requires:
• awareness of your patient demographics, ‘what’s affecting who?’
• knowledge of the specific disease state, ‘what is it all about?’
• program / plan, ‘how am I going to do it?’
• up-to-date resources incl. templates, ‘what am I doing with it?’
• recall and reminder system, ‘what now?’
Awareness
Knowing your patients/demographics.
General awareness, eg. aging area v younger population, this will affect who you are targeting and how you will target.
PENCAT Tool, and some data extraction through clinic software…
Knowledge
Having an understanding about the disease state.
Background understanding is a great place to start, increasing on your knowledge increases the amount you can impart with a patient. Transitions from being an ‘information session’ to a time of providing education.
Program / Plan
How much time has the clinic dedicated to care planning
What resources are available eg, room and equipment
Are reception staff involved /aware?
All all GP’s involved in care planning?
How many patient’s will be seen per session, how are they going to be followed up with GP?
Resources
• Patient handouts – some will take home information and read it…
• Direct patients to various websites – some are interactive…
• Posters & models – some people are more visual/textual learners
Don’t be shy about asking for patient information, but also don’t be shy about not taking it either…
• Templates – do they fit your practice?
Medical software has some available, as well as local divisions GPNS, ANPGP… Also, you can develop your own.
Templates
• Explained the steps involved, and the patient has agreed
• Identify and/or confirm diagnosis
• Agreed management goals
• Identified agreed actions
• Identified treatment options / services (TCA)
• Date for review.
Billing
Item numbers are there to be billed.
Medicare has documented the item number / billing information in a complicated manner… Ultimately:
New Plan + TCA - 721 + 723 + 10997
Review - 732 + 732 + 10997
Review + Diabetes Cycle of Care - 732 + 732 + 10997 + 2517
New Plan + TCA + Cycle of Care + ECG - 721 + 723 + 10997 + 2517 + 11700
Recalls
Medicare suggests reviewing patients every 6 months, but item numbers are claimable at 3 months.
A recall system is something that needs to be tailored to each clinic, but some things to consider may include:
• staff availability, who is generating letters, making phone calls • patient preference, do they respond to letters or phone calls better
www.gpns.org.au www.aep.net.au www.apna.asn.au
www.anf.org.au www.hsfinder.sa.gov.au www.mbsonline.gov.au
www.affa.net.au www.diabetessa.gov.au www.enurse.com.au
www.healthysleep.net.au www.gp.org.au
Thank you for time this evening
Donna vonBlankenseeRN grad.cert cdsma
c.d.program.developmentP: 0422 307 152E: [email protected]: www.cdprogramdevelopment.com.auF: Practice Nurses SA
