Part 2 ROLES: The Chronic Conditions Management Team in General. Practice. Inside this section. A Guide to Chronic Condition Management

Transcription

1 A Guide to Chronic Condition Management Part 2 ROLES: The Chronic Conditions Management Team in General Practice Inside this section The Chronic Condition Management Team in General Practice 43 Roles in General Practice 44 GP Role Practice Nurse Role Nurse Led Clinics Front Line/Administration Staff Role 58 Practice Manager Role 59 TMML s Role 60 Self Management Role Websites 68 Compiled by Townsville Mackay Medicare Local January

2 The Chronic Condition Management Team in General Practice GENERAL PRACTITIONER ROLE PRACTICE NURSE ROLE PRACTICE MANAGER ROLE GENERAL PRACTICE ROLE FRONT LINE PRACTICE STAFF ROLE TGPN ROLE Compiled by Townsville Mackay Medicare Local January

3 The Chronic Condition Management Team Literature and evidence based clinical pathways indicate that effective management of patients with a chronic condition requires a multi-disciplinary team based approach. Within general practice, a team would usually include the GP and an Advanced Practice Nurse with other health professionals such as Dietitian, Podiatrist, and Optometrist for example, brought in as part of team care arrangements. Practice Managers and Administration/Front Line Staff also have an important role in maintaining and sustaining systems that the General Practice implements to manage people living with Chronic Conditions. Roles in General Practice Australian and international evidence indicates us that effective chronic condition management in general practice requires a combination of the following factors: Effective systems such as patient information and education resources, clinical decision making support tools, patient chronic condition registers, and recall and review mechanisms; Patient education and support, assistance with managing their own medical conditions and self management; Establishing and maintaining good linkages with community resources and services; Effective team work between health providers within the practice and with other health professionals. The literature suggests that business processes, systems and cultural change are required within general practice to strengthen primary care and chronic condition management. For example a practice may need to review the range of services offered, redevelop its infrastructure and systems, and introduce continuous improvement processes such as Plan-Do-Study-Act (PDSA) cycles. The growing burden of chronic disease and patient demand has increased GP workloads. Nurses in general practice work with GPs to provide efficient and effective health care to all patients. The research also shows that the employment of practice nurses and/or the establishment of nurse led chronic condition clinics in general practice can improve patient care and outcomes for people with a chronic condition, as well as address practice issues such as systems and cultural change, and GP workload. Testimonial As a practice, Woodlands Family Practice was quite reluctant to become involved in care planning. The practice principles, in particular felt that the care they were delivering was according to accepted guidelines and they did not need a more formalised approach. We were concerned as a practice that care plan item numbers were more about generating income than good patient care and we didn t want to go down that slippery slope. In 2008 we were approached by Townsville General Practice Network to participate in the Enhanced Diabetes Program and shortly after that the Australian Primary Care Collaboratives program. As a result of participating in both these programs, we looked more closely at the care we were delivering and realised that there were gaps in that care and that by taking a more structured team approach we could definitely improve the health outcomes of our patients. As we were already involved in the enhanced diabetes management program and as one of the focus area for the collaboratives is diabetes, our diabetes patients earned the dubious honour of becoming our guinea pig target group. Maria Finn - Practice Nurse Compiled by Townsville Mackay Medicare Local January

4 General Practitioner Role GP involvement in chronic condition management is essential, as the GP has overall responsibility for the patient s care and ensuring compliance with the MBS item number requirements. To sign off on MBS items such as GPMP and TCA To provide medical management (Medications, pathology and diagnostic requirements) To communicate effectively with and liaison with all team members Role of the General Practitioner in Chronic Condition Management To identify suitable patients for chronic condition management To prescribe medications and assess effectiveness To provide ongoing medical care for patient involved in chronic condition management To promote the practice policy on chronic condition management to patients GP input and sign off - One example of a way to integrate the practice team. When a clinic runs nurse led chronic condition clinics, to operate these clinics effectively GPs need to be able to attend the clinic at specific times during the session. This may mean that special appointments are made, or times flagged, for the GP to attend the clinic. At other times the nurse may need to seek advice from the GP, hence flexibility of, and access, to GPs on clinic days is essential. When the patient attends an appointment at the clinic, the GP is advised on his/her appointment schedule. The GP then knows he/she will be required to be present towards the end of the appointment. The clinic nurse rings the GP 5-10 minutes before the patient has finished their clinic appointment, allowing the GP time to finish with their current patient and then attend the clinic in a timely manner. Compiled by Townsville Mackay Medicare Local January

5 Benefits of developing a chronic condition management for General Practitioners Well managed and effective chronic condition management in general practice can provide the following benefits for the GP/s: Increased number of patients who can be seen by the GP Increased income generated through the involvement of an Advanced Practice Nurse Improved work satisfaction from working in a multi-disciplinary team and improving patient outcomes Increased capacity and expertise within the practice Increased range of services available for patients Improved efficiency in the use of GP time spent in chronic condition management Shared responsibility for chronic condition management Increased ability to claim the Diabetes and/or Asthma Service Incentive Payment (SIP) Increased numbers of completed General Practice Management Plans (GPMP) and Team Care Arrangements (TCA) Improved recall and review system Improved self management and behaviour change by patients Testimonial Chronic disease / EPC item numbers etc seemed to us to be such a bewildering bureaucratic obfuscation that it was preferable to ignore them. We had the usual excuses- too busy seeing sick people, pointless paperwork, ethically opposed, wary of underlying agenda's etc. Medicare seems to want to reward us for practising in evidence based way and monitoring outcomes. We thought we were already doing this reasonably well, and with the chronic disease program offered by TGPN we could actually discover if we were, (which we thought would be important to know),and at the same time get a hefty push up the EPC learning curve. What happened? We had to sort out our data, which meant getting full and consistent use of our clinical software. This has been a very good thing and not as difficult as we imagined. We discovered that we were doing OK with our management but had room to improve- no nasty surprises. We are now doing a lot more EPC items and getting paid without too much change in the way we practise. Our RN's enjoy it, patients are mostly pleased with the extra interest in their plight and have responded with enthusiasm, and even some meaningful lifestyle changes. We can see our own progress and are less concerned about the red tape and more about the outcomes. Like all medicare items, bill appropriately and you should sleep soundly. The chronic disease team from TGPN are very calm (they need to be), very knowledgeable and very helpful. Make use of them and prosper! Regards Dr. Martin McGahan GP at Woodlands Surgery Compiled by Townsville Mackay Medicare Local January

6 The Practice Nurse Role A practice nurse is a registered nurse or an enrolled nurse who is employed by, or whose services are otherwise retained by, a general practice.(recruitment and Orientation Resource ) Practice nurses work in collaboration with general practitioners providing a range of services, including chronic condition management and population health activities. Their role is diverse and influenced by factors such as the practice population, nurses qualifications, practice structure, professional standards and national incentives and programs. They provide preventive and chronic care for people of all ages. AGPN - Nursing in General Practice Program Testimonial Practice nurses can assist with the provision of quality chronic condition management (CCM). This care must be provided under the general practitioner s supervision. An advanced practice nurse can assist the GP in preparing or reviewing a care plan for example, in assessing the patient, identifying the patient s needs and making arrangements for services. This assistance is provided on behalf of the GP. The GP must review and confirm all assessments and elements of the service and must see the patient. Nurses can be involved in organising the chronic condition management systems and processes in the practice, as well as having an on-going role in assisting to identify eligible patients. Informed patient consent is required when using a practice nurse. If the patient refuses, this needs to be documented in the patient s notes. From 1 July 2007 Medicare item number applies to the provision of monitoring and support of people with a chronic condition by a practice nurse or registered Aboriginal Health Worker on behalf of a general practitioner.(medicare Online website Condition Specific Clinics Advanced Practice Nurses can be involved in setting up condition specific clinics such as diabetes or cardiac clinics and allocated sessions to perform assessments and develop care plans with patients. Nurses can be involved in health promotion and patient education aspects within the practice. Some practice nurses may have other qualifications or special expertise to provide specific ongoing care, such as an Asthma Educator. There needs to be adequate space within practices to support nurses taking on these roles. Patients need to be informed about the practice nurse role. Informed patient consent is required when using a practice nurse. If the patient refuses, this needs to be documented. Compiled by Townsville Mackay Medicare Local January

7 What is the role of an Advanced Practice Nurse? A nurse led clinic should be staffed by an Advanced Practice Nurse who has additional education in chronic conditions such as diabetes and coronary heart disease as advanced nursing practice is required. To ensure systems support the effective operation of the clinic To provide advanced clinical support to the patient and the practice To work as part of a team Role of an Advanced Practice Nurse in Chronic Condition Management To provide quality care to patients with a chronic condition To manage and run the clinic in conjunction with practice staff Compiled by Townsville Mackay Medicare Local January

8 Nurse led clinics - what s involved? This section of the Guide describes some features of a nurse led chronic condition clinic in general practice. The diagram below provides an overview of the essential elements of a nurse led chronic condition clinic in general practice. Setting up a Nurse-led Clinic Testimonials SET UP CLINIC 1. Staffing 2. Room & Equipment 3. Support Systems 4. Finances Prepare Practice Staff The best advice I could offer to any nurse/practice wanting to get more involved in chronic condition management and care planning is firstly, do the ground work. Clean up your patient data bases and ensure you have accurate registers. The support given to our practice by division staff was wonderful. I really don t think we could have progressed even as far as we have without their help. Secondly, get involved in the various support groups run by the Division. They are a wealth of information and support. Nurses at these groups are more than happy to share their own experiences of what did and didn t work for them. It could save you a lot of time learning from their successes and failures. Thirdly, make sure you have support within your own practice at all levels, clerical, nursing and medical. You can t do it on your own. Maria Finn - Practice Nurse I was asked to write a few lines about how we developed a chronic disease program at our surgery. Recruit Patients It has been a wonderful journey but not without the usual frustrations. We where lucky to be a new surgery with a limited clientele and previously I had worked and ran several clinic's which made it easier for me. I had an idea of what I needed to do. Operate Clinic Getting new staff to change their way is so difficult, they put up barriers along the way. There is always a reason why we can not do it; the patients would not like it and so on. Well the patients love it; they get a nurse who is willing to listen to them for a whole 1/2 hour. They have input into their treatment and have a better understanding of their disease. Evaluation & Continuous Improvment At first we did opportunistic care plans and team care arrangements, this is fine but you need a more reliable system where you know that the patients are going to be seen for on a regular basis. Marlene Griffiths - Practice Manager/Practice Nurse at Health & Wellbeing North Ward. Compiled by Townsville Mackay Medicare Local January

9 The benefits of nurse led chronic condition clinics in general practice Australian and international research highlights a range of benefits that nurses and nurse led chronic condition clinics can bring to general practice. These include improved health outcomes in chronic conditions, assistance in primary acute care integration, better coordination of care, increased workforce capacity, the provision of practical and professional support to GPs, and the enhancement in the range of services available to people attending the practice. A well managed and efficient nurse led chronic condition clinic can provide the following benefits to a practice: Increased income and profit, contributing to the long term viability of the practice Increased range of services offered at the practice Improved systems such as appointment bookings, billing, and recall and review Improved integration and partnerships with the acute sector and the primary care system Improved working relationships and a multi-disciplinary approach within the practice, and with external health professionals Improved quality of care for patients including meeting clinical guidelines and systematically delivering the requirements of the annual cycle of care Reduced patient waiting times Improved management of patients with a chronic condition including self management support Improved health outcomes through screening, prevention, assessment, patient education, management, care planning and reviews Enhanced patient satisfaction What is a nurse led chronic condition clinic? A nurse led chronic condition clinic is designed to provide patients who have chronic conditions with additional support and strategies to self manage their condition. A clinic usually runs in a set and protected time during a practice s usual business hours, so that patients can access both nursing and GP support for their chronic condition. A clinic can focus on a specific chronic condition such as Diabetes or Asthma, or have a general focus for people with a chronic condition. Patient appointments in the clinic can be booked in advance, usually for a half an hour block, with a long appointment booked (one hour) for the initial assessment. Compiled by Townsville Mackay Medicare Local January

10 The core activities of a chronic condition clinic include: An initial assessment Management of the annual cycle of care Development and implementation of a patient education program Discussion and setting self management goals, and re-establishing these if the patient relapses Setting clinical targets and strategies to pursue i.e. HbA1c of less than 7% or Cholesterol of less than 4.0mmol/L for diabetes patients Strong linkages with GP management including medication management Development of a care plan (GP Management Plan) Shared care with other health professionals (Team Care Arrangements) Referral to other health professionals for specific care requirements Ongoing review and support (GPMP, TCA, self management goals etc) The initial assessment can be funded through the MBS using key items such as the GP Management Plan (GPMP) and Team Care Arrangements (TCA). What is involved in an initial assessment? An initial assessment for a patient with DIABETES who is referred to a nurse led chronic condition clinic, is likely to include: An initial assessment for a patient with ASTHMA who is referred to a nurse led chronic condition clinic, is likely to include: Completion of anthropometric tests including height, weight, blood pressure and blood glucose Discussion of the pathophysiology of Diabetes and general treatment Detailed investigation and analysis of diet and exercise Assistance to undertake home glucose monitoring Discussion of Medications Complications screening Development of a GP Management Plans and Team Care Arrangement if appropriate Patient s self-management goals Development of Action Plans Completion of tests including a Spirometry test Discussion of the pathophysiology of Asthma and general treatment Review of device use Development of a written Asthma Action Plan Recruiting the patients for a Nurse led Clinic A nurse led chronic condition clinic will not be successful without a steady flow of new patients. There are many ways to recruit patients including: Regular promotion of the clinic, its services and its benefits through newsletters, fliers, letters, and posters. Opportunistic referral of patients to the clinic by the GPs and other practice staff such as referring all newly diagnosed patients or patients who present for other care and who would benefit from the services of the clinic. Generation of chronic condition lists /registers by the practice and targeted marketing to these Patients. Compiled by Townsville Mackay Medicare Local January

11 Operating a viable clinic The Practice Manager and/or Practice Principal are responsible for the viability and sustainability of the clinic. However, the nurse should be responsible for managing the day-to-day operation of the clinic such as organising his/her own time, re-ordering health promotion materials, building relationships with external health professionals, alerting the practice to areas for improvement etc. It is anticipated that appointments will run consecutively and the maximum number of patients will be booked into each session. The clinic time should be used at the nurse s discretion, with appropriate time before and after each patient to complete paper work and follow up. For example the nurse may choose to complete paper work and phone calls at the end of each appointment or at the end of the session. A Benefits for patients A well managed nurse led chronic condition clinic in general practice can provide the following benefits for patients: Increased satisfaction from having their needs met and adequate time to discuss issues related to their chronic condition Improved clinical outcomes such as reduced HbA1c and improved weight management Increased knowledge and understanding of their chronic condition Supported self management e.g. Motivation, diet, exercise, life style change, medications management and device use, symptom monitoring and complications prevention Increased range of services available at their general practice Improved access to health professionals i.e. through the MBS Allied Health items Improved quality of life Nurses in general practice have the time and caring characteristic that patients believe enables the nurse to have a significant role in providing support, health information or in assisting patient understanding. Melbourne East GP Network Nurse Led Clinics (2007) Compiled by Townsville Mackay Medicare Local January

12 Benefits for nurses A well managed nurse led chronic condition clinic in general practice can provide the following benefits for nurses: Improved recognition of the nurse contribution to care; Increased employment and career opportunities; Improved job satisfaction; Increased opportunity for training and specialisation e.g. a Practice Nurse may undertake a post graduate qualification and become a Diabetes Educator/Nurse Practitioner; Increased opportunity to use skills and knowledge; Increased team work and the opportunity to work in a multi-disciplinary team. Other MBS Items relevant to a nurse led chronic condition clinic There are a number of other MBS items which can be used to support and finance a nurse led chronic condition clinic including: Items Numbers Item Item Item Items 700 to 719 Item Item Item Description Ankle Brachial Index (ABI) Spirometry Stick Prick Allergy Testing Health Assessments Wound Management Immunisation by a Practice Nurse CCM Item for Practice Nurses Please refer to the following web site for up-to-date information on items and rebates Items numbers are updated by Medicare every November and May. Setting up the clinic Before the clinic can open its doors, there is some set up work required. TMML can have important role to play in assisting practices with the set-up phase. The four essential areas to consider in the set-up stage are: Stage 1- Staffing the clinic and identifying the chronic condition team Stage 2 - Preparing the clinic room and equipment Stage 3 - Redeveloping systems to support the clinic i.e. Appointment booking and recall & review Stage 4 - Organising the billing and clinic finances including MBS items and paying clinic costs During the set up stage there are also some risks and barriers to look out for including: Reluctance by Reception staff to change We ve always done it this way! ; A lack of skills and competencies in key areas such as recall and review, billing and marketing; Communication difficulties, such as the GPs roles not being explained properly and as a consequence GPs not understanding their roles and responsibilities. In particular, GPs may need to be available during clinic times to attend each patient; Compiled by Townsville Mackay Medicare Local January

13 Negative attitudes such as a reluctance by GPs to promote the clinic or a reluctance by Reception staff to contact patients to remind them to attend appointments. Stage 1 - Staffing the clinic and identifying the chronic conditions team Once the scope and nature of the clinic has been determined, then appropriate staff should be recruited and the care team identified Develop the position description and recruit the nurse. If the clinic is an expansion of the Practice Nurse role, TMML can provide advice to the practice about clinic requirements and training for the Practice Nurse in key areas such as billing, recall and review, clinical guidelines and chronic condition management. It has not been an easy journey and we have certainly hit a few pot holes as we travelled along. Testimonial Finding time for already busy nurses to participate in care planning was very difficult and the option of employing more nursing staff was made difficult by the shortage of nurses willing to work in general practice. Another hurdle we faced was space for the nurses to be able to spend time one on one with the patients. We were lucky that our surgery is situated very close to the local community centre and we were able, with the support of the TGPNs IT Team, to use an office at the centre and have remote access to the practice server. By far the biggest problem was actually developing the processes needed for setting up and running a chronic condition clinic. This is a process that is still evolving. Maria Finn - Practice Nurse Importantly managing chronic conditions requires a team based approach. This can require the establishment of new working relationships within the practice as well as building links with health professionals outside the practice. At the set-up stage it is worth considering what local services and health professionals can be included in the team (private and non government) and approach them to build your team approach. Compiled by Townsville Mackay Medicare Local January

14 Stage 2 - Preparing the clinic room and equipment For a clinic to operate effectively and efficiently, it requires an appropriate space (room) and equipment. Ideally the practice will have a separate room for the clinic, or perhaps a consultation room which is available. The minimum requirements for a clinic room include, sufficient space for a comprehensive assessment and the provision of appropriate clinical care. Equipment: Room for a desk, phone, computer and printer to enable the nurse to access patient records and make referrals in a timely manner A telephone for internal communication with the GPs and external communication with other health professionals for referral and Team Care Arrangements Hand washing facilities Appropriate equipment e.g. Scales, height chart, BP machine. Specific clinics may require specific equipment e.g. Blood Glucose Meter, Spirometer etc Storage space for clinic resources, such as health promotion materials and patient aids Adequate safeguards for patient privacy and confidentiality Occupational health and safety standards Stage 3 - Redeveloping systems to support the clinic i.e. Appointment booking and recall and review Appointments system: To ensure the clinic meet clinical guidelines including the Diabetes annual cycle of care and are financially viable, it is a good policy that no patient leaves the clinic without a follow up appointment. If appointments are cancelled, it is highly recommended that they are automatically rebooked by the Receptionists at the time of cancellation. In addition, the patient receives a written confirmation letter setting out the details of the new appointment time, with a reminder call the day before the appointment. The nurse activates the practice recall system as a final back up for all appointments, This: Ensures patient attends all appointments proactively which reduces reactive and acute appointments; Enables practices to maximise income from CCM items; Supports the achievement of the annual cycle of care (including the Diabetes SIP); Ensures clinic appointments are at least 75% full at each clinic if patients regularly cancel, the nurse rings to discuss barriers and encourage the patient to return to the clinic. Compiled by Townsville Mackay Medicare Local January

15 Increased income and profit, contributing to the long term viability of the practice Enhanced patient satisfaction Improved health outcomes through screening, prevention, assessment, patient education, management, care planning & reviews Improved management of patients with a chronic condition including self management support Improved systems such as appointment bookings, billing, and recall and review Benefits for a general practice developing a Chronic Condition Nurse Led Clinic Reduced patient waiting times Improved integration and partnerships with the acute sector and the primary care system Improved working relationships and a multi-disciplinary approach within the practice, and with external health professionals Increased range of services offered at the practice Improved quality of care for patients including meeting clinical guidelines and systematically delivering the requirements of the annual cycle of care Testimonial The rewards are great, excellent patient care, meet all the Medicare requirements and documentation is up to date and accurate. It sounds simple and it is; there are a few things that make it hard. Finding the time to commence, allocating a nurse to clean the register and having the nursing staff to sit down with the patients. Once you have that in place it s a wonderful way to give your patients the care they need and should have, and very satisfying for the nursing staff. Marlene Griffiths - Practice Manager/Practice Nurse at Health & Wellbeing North Ward Compiled by Townsville Mackay Medicare Local January

16 EPC Clinics A practice perspective In June 2006 we made the decision to improve the processes we have in place for our diabetes patients. We needed to make changes that improved our knowledge of our diabetes patients and our processes for handling them. Our hope was to become more proactive in their health care and provide the patients with information and motivation that would empower them to better monitor and maintain their own condition. The model to achieve would have the dual benefit of improving the health of the patient group as well as improving the financial outcomes of the practice. This was attained by using the GP Management Plans and Team Care Arrangements combined with checklists as the means of monitoring the patients and involving other health professionals to assist in the care, and motivation of the patients. We commenced by collecting information from our Practice Management System database to find out who were our diabetes patients and which ones were still actively attending our Practice. This resulted in a diabetes register which enabled us to monitor those patients with ease. We then decided on a set of outcomes that we could measure so that we would have an understanding of what level our patient group was at (baseline data) and then continue to measure these outcomes over time to see if the changes we planned to introduce were having a positive effect. Business relationship were established with key allied health so that we could have confidence in involving them in Team Care Arrangements and know that they were keen to be part of the team to improve the patient s health. We commenced running a diabetes clinic on one morning a month and contracted the services of a dietician and exercise physiologist to attend on the clinic mornings to be part of the process for providing the patients with information and motivation. Testimonial Over the last two years the clinics have evolved to include differing forms of chronic conditions. We now run the clinics about every 6 weeks and only utilise them for patients who are newly diagnosed or who are not well controlled with their chronic condition. Paul Goulding - Practice Manager at Townsville and Suburban Medical Practice Compiled by Townsville Mackay Medicare Local January

17 Administration/Front Line Staff Role Role of Reception staff To be openly supportive of Chronic Condition Management and promote its benefits to patients To have a working knowledge of all the components and systems required to support chronic condition management in the practice To actively manage booking of appointments, rebooking and cancellations To organise the reminder and recall requirements To coordinate clinic billing To participate in continuous improvement Clinic billing The financial viability of a chronic condition management will be dependant on the practice ensuring an appropriate billing system is in place and that it is being implemented. For most practices, this will involve simply refining existing systems to ensure: All relevant MBS items (such as the Diabetes SIP) for chronic condition management are programmed into the computer; Reception staff are familiar with the relevant MBS items and how to claim them; There is a clear process to communicate to front of house staff which MBS items need to be claimed; It is clear how the patient will be charged i.e. bulk-billed, co-payment or privately billed. To ensure all the appropriate items are being claimed correctly, the practice should review its billing system: At the end of the first nurse-led clinic if applicable, the end of the first month and at the 3 month mark When there are changes to the Medicare Benefits Schedule (usually May & November each year) As Chronic Condition Management will predominantly make use of the Enhanced Primary Care Chronic Condition Management items, it is important that the practice s billing systems are geared up to claim the appropriate items. This may be as simple as adding a couple of extra tick boxes to the billing slip the GPs give to patients to take to Reception at the end of the consultation. In fully computerized practices, it may be as simple as providing training in this area for Reception staff. Whatever system the practice chooses to use, it is recommended that the practice regularly review its billing and billing processes to ensure it is claiming correctly and meeting the MBS requirements. Where there are staff changes either in the nurse-led clinic or Reception Testimonial We didn t provide information to the Reception staff about the new MBS items we would be using in our nurse-led clinic. As a consequence they were unfamiliar with the MBS item numbers the nurse was billing, and assumed she was mistaken, and they continued to bill for standard consultations using the MBS items they were used to using. Practice Testimonial Compiled by Townsville Mackay Medicare Local January

18 Practice Managers Role To ensure Reception staff support Chronic Condition Management within the practice To ensure systems support the effective operation and funding of chronic condition management To ensure appropriate billing occurs The Role of the Practice Manager To ensure ready access to a clinic room, clinic equipment and resources To regularly review and continuously improve the systems which support chronic condition management To provide support to the nurse and encourage a team based approach Finances including using MBS items and paying for the chronic condition management. For chronic condition management to be financially viable and sustainable, the practice will need to have in place a clear financial and business model, which includes systems for billing appropriately for the clinic services. (See EPC/CDM item No Section of this guide) Preparing practice staff By taking a whole of practice approach and addressing each person s role in a process, everyone becomes part of the team and works more effectively towards a systematic approach. An important role for the Practice Manager can be to assist the practice to clarify roles and responsibilities of practice staff Practice Manual A Practice Manual is a useful way of setting out the roles and responsibilities of all those involved in chronic condition management and helps to orient new staff. A Practice Manual could include: Practice Manual Information on chronic condition management systems, nurse led clinic details, hours etc Patient eligibility, specific target groups and referral pathways Letters and templates, with guidelines on how to use them Roles and responsibilities statements for GPs, Reception staff, Practice Nurse, Clinic Nurse etc Booking Guidelines Appointment Guidelines Medicare Item numbers used in chronic condition management Privacy and consent requirements Quality Improvement and Plan, Do, Study, Act (PDSA) cycles and tools Compiled by Townsville Mackay Medicare Local January

19 Townsville - Mackay Medicare Local Role The role of Townsville - Mackay Medicare Local encompasses the following activities: Promoting the benefits of systemized chronic condition management amongst its practices and GPs; Providing advice and assistance to practices interested in establishing chronic condition management; Assisting practices to review and redevelop systems, the development of templates for care planning, and assistance to develop policies and procedures to support the development of chronic condition management; Providing on-the-job training to practice staff including Administration staff, in key areas such as appointment bookings, billing, recall and review; Providing material such as marketing materials and health promotion resources; Assisting practices to review and continuously improve health outcomes for people living with chronic conditions; Providing information and advice on MBS items and annual cycles of care etc; Trouble-shooting advice and support; Supporting Practice Staffs professional development, to implement systems change, with insurance and legal issues; Provide ongoing training and information on trends in best practice and government stratergies e.g. self management; Provide information of community based support allied health, community organisation,non government organisations and community groups. Benefits for the General Practice Networks Well managed and effective Chronic Condition Management in general practice can provide the following benefits for GP Networks: Benefits for the Divisions of General Practice Increased recognition of the GP Network s role in supporting practice improvement and nursing services Increased opportunity for the GP Network to promote and lead the expansion of Advanced Practice Nurses in general practice Increased learning s about the benefits and opportunities of nurses in general practice Enhanced opportunity for the GP Network to build effective working relationships and trust, and to roll out other programs such as e-messaging and Quality Use of Medicines etc in the practice Increased GP Network s profile and rapport with GPs, practice nurses and practice staff Enhanced quality of data management in the practice and use of this data to improve health outcomes Benefits for the health service system Well managed Chronic Condition Management in general practice can provide the following benefits for the health service system: Improved working relationships and communication between general practice and other primary care providers; Improved capacity to provide self management support to patients with a chronic condition; Increased referrals to other health professionals (for example Allied Health) and local programs (such as exercise groups, health promotion activities) for people with a chronic condition; Increased business for private providers willing to work collaboratively with general practice e.g. Using the MBS Allied Health and Dental Services items. Compiled by Townsville Mackay Medicare Local January

20 What is the role of self management in chronic condition management? Day-to-day responsibilities for the care of chronic conditions fall on patients and their families. Therefore it is necessary to enable patients to play an active role in their health by delivering care in collaboration with the patient. Enabling patients to play an active role in their health requires health services to provide not only good medical and clinical treatment but also to improve the knowledge and self management skills of these patients with chronic conditions. Improving knowledge and skills involves more than the provision of education. Rather, health professionals need to adopt a more structured approach to supporting improved patient self management. Patients are supported by the health worker to improving their self management includes activities that develop patient problem-solving skills, improve self-efficacy and support the application of knowledge in real-life situations that matter to patients. Compiled by Townsville Mackay Medicare Local January

21 Why is Self Management Model important? 14-21% of patients never fill prescriptions 30-55% of patients don t take medication in the recommended way 50% of patients have difficulty in adhering to Lifestyle changes 60% of patients don t tell their doctor they smoke. (UCLA 2009) The four key action areas of the National Chronic Disease Strategy are to be considered Reorienting the health system to support selfmanagement Prioritising patient participation in care planning National Chronic Disease Strategy Improving the capacity of the peer, disability and carer support sections Tailoring self management approaches to individual and community need The National Chronic Disease Strategy approach comprises three components 1. The National Chronic Disease Strategy - provides an overarching framework of national direction for improving chronic condition prevention and care in the Australian population. 2. National Service Improvement Frame work has been developed for asthma, caner, diabetes, heart/stroke/vascular diseases, arthritis/rheumatoid arthritis and osteoporosis to reduce the impact of these chronic conditions. 3. The blueprint for nation-wide surveillance of chronic conditions and associated determinants through essential elements agreeing on priorities, methods and proposed immediate actions Compiled by Townsville Mackay Medicare Local January

22 The common themes of the strategy, framework and blueprint include: An emphasis on health promotion, prevention and monitoring population trends in risk factors for chronic conditions Supporting integrated service provision and multidisciplinary care Promoting and supporting self-management within the health system Progressing mechanisms to improve quality of care and Improving access to chronic condition prevention and care services by Aboriginal and Torres Strait islander people and other under -services population groups. Self- management is one component of the Chronic Condition Model. The World Health Organization The World Health Organization has developed an expanded version of the Chronic Care model, the Innovative Care for Chronic Conditions Framework, designed in particular to be relevant to low and middle income countries. It broadens and reframes the Chronic Care Model by organizing the evaluation along macro (policy and financing), meso (health care organization and community) and micro (patient and family) levels of the health care system. This framework is centred in a triad of partnership between the patient, the health care team and the community. This triad is placed in the background of organized and well equipped health care teams and a positive policy environment. These models are comprehensive and seek to provide high quality care as well as continuity, while involving patients, communities, health care teams, and policy makers. In the provision of effective chronic care, attention to the areas listed above can lead to positive outcomes. Expanded Chronic Care Model Compiled by Townsville Mackay Medicare Local January

23 What is effective self management support by a Health Workers? The following components should be considered in effective chronic condition self management: Collaboration Personalised care plans Self management education Programs that have successfully improved self-management have the following characteristics: Targeting Goal setting Planning. Adherence to treatment Follow-up and monitoring The Six Principles of self - management The following characteristics are considered s summary of a good self manager. They are individuals who Six Principles of Self- Management Have knowledge of their condition Follow a treatment plan (care plan) agreed with their health worker Actively share in decision making with health workers Monitor and manage signs and symptoms of their condition Management of the impact of the condition on their physical, emotional and social life Adopt a lifestyle that promotes health Collaborative Patient Centred Practice Collaborative patient centred care promotes active participation of all health worker disciplines. It enhances patient, family and community centred goals and values, provides continuous communication among providers, increases staff participation in clinical decision making (with and across disciplines) and fosters respect for all contributions of all providers. Patient Centred Care Patient centred care shares management of the condition between the person and the health provider. There are various definitions of patient centred care. The main elements are: effective communication with the person with the condition; partnerships a focus beyond the specific condition o on health promotion o and healthy lifestyle. Compiled by Townsville Mackay Medicare Local January

24 Patient Centred Planning Increasing effectiveness of self management involves an ability to indentify and respond to individual peoples needs using appropriate planning tools at the start, on going coaching and follow-up. Patient centred care plans developed collaboratively by the person with their health care provider, are the central tool that allows for and promotes self management of chronic conditions. A complete care plan outlines the health care and goals for a one to two year period. The plan recognises the expressed needs and goals of the person. It will include a program of health monitoring activities and education of condition specific or a general nature. A person centred held document provides a portable record of person medical history, medications, immunisations, allergies, health providers and a current health plan. Gp s have critical role in care planning process. Experience suggests that explanation and an initiation from Gaps during consultation is the most effective strategy for recruiting people into the care planning process. The provision of a range of EPC items recognises the importance of their process. Others health care providers can contribute to the process of a care plan but the plan must be authorised by the GP. Targeting Action Planning Targeting the expressed needs allows health workers to focus on one concern at a time. The concern chosen should be based on the importance of the problem to the patient with support in identification from the health worker, and patient readiness for change. Goal-setting and action planning are part of the seven core skills required: Reflective listening and using open-ended questions Identifying patients readiness to change Motivational interviewing / Coaching Problem solving and identification Produce a care plan Action plan interventions Refer patients to community interventions Targeting concerns is a necessary skill for patients with a chronic condition to learn. It can be taught to patients to enable them to make confident decisions concerning their health. In allowing the patient to identify the concerns using the following tools enables health workers to assist people to identify their areas of need, solve barriers to change, and raise key clinical markers. Compiled by Townsville Mackay Medicare Local January

25 Well-formed reflective statements won t evoke resistance but encourages expressed arguments for change. Reflective listening is the most important skills of coaching and motivational interviewing Open-ended questioning creates acceptance and trust and allows patients to explore their concerns. In this skill, Patients talk and health professionals listens with reflective listening. This allows patients to establish their own reasons for change. Reflective listening is an active process that reflects back to the patient the meaning of what they have just communicated. It is a way of checking rather than assuming that you already what is meant. "The Skilled Helper" by Gerard Egan (2006) Problem Solving Care Planning Dealing with the emotional impact of having chronic illness, which alters one's views of the future. Emotions such as anger, fear, frustration and depression are common. Motivational interviewing leads decision making. With directive questions and reflective listening, patients make their decisions by exploring their uncertainties. By identifying problems patients find their own solutions. Information about community services or community groups is provided. Including the "Stanford" course Better Health Self Management program. Use assessment tools to assess the patient s ability to self-manage. The Flinders program provides individually designed care plans that focus on self-management Setting Self Management Goals with the Person Once the main concern has been identified a clear goal can be establish with the patient and the health worker What is the main concern (problem statement)? What do you see as your main concern? How does this affect the way you live? How does this make you feel? Setting a goal What would you like to do that this stops you from doing? (make it realistic and achievable) What do you need to do to make this happen? (first steps sub goal ) I don t eat out as much as I would like to because I don t know what to choose from the menu at a restaurant I feel isolated from my family and friends I feel depressed and sad I will learn how to make healthy choices from a restaurant menu I need to make an appointment with a Dietitian Compiled by Townsville Mackay Medicare Local January

26 SMART Goals are S- Specific (doing something) M- Measurable (observable) A- Action based R- Realistic (not to reliant on others) T- Timeframe (how long/how often) An example of a SMART Goal is - I will catch the bus to the craft centre on Tuesday afternoon at 2 pm for one month. Does it have above components? Common Chronic Condition Self Management tools Compiled by Townsville Mackay Medicare Local January

27 Resources - Websites Roles in General Practice RACGP Australian Practice Nurse s Association Practice Nursing in Australia Australian Nursing Foundation Competency Standards Royal College of Nursing Australia Australian General Practice Network Nursing in General Practice Recruitment and Orientation Resource Australian Association of Practice Managers Melbourne East GP Network Practice Nurse Information Self Management Resources Flinders Human Behaviour and Research Unit Health Coaching Australia Self-Management Program CDMS Support Guide developed by EPDGP & SGRHS TMML Website Chronic Condition Self Management Compiled by Townsville Mackay Medicare Local January