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

28 A Guide to Chronic Condition Management Part 3 Quality Improvement Managing Change in General Practice Inside this section The Improvement Model Change Principle 1 73 Change Principle Change Principle Change Principle Change Principle 5 80 PDSA Examples RACGP Rapid PDSA Cycles for 40 Category 1 points RACGP Clinical Audit for 40 Category 1 points RACGP Small Group Learning for 40 Category points Websites 94 Compiled by Townsville Mackay Medicare Local January

29 Managing Change in General Practice The Improvement Model Making improvements in services requires change. Change can seem threatening or overwhelming for busy people doing demanding work. The Plan-Do-Study-Act (PDSA) method is a way to break down change into manageable chunks, and test each small part to make sure that things are improving and no effort is wasted. Making changes to the way that we do things can be time-consuming and can sometimes feel risky. The model for improvement is a tried and tested approach to achieving successful change. Use of the model offers the following benefits: It is a simple approach that anyone can apply It is highly effective The Improvement Model It reduces risk by starting small It can be used to help plan, develop and implement change The model consists of two parts that are of equal importance. The first, the thinking part, consists of three fundamental questions that are essential for guiding improvement work. The second part, the doing part, is made up of Plan, Do, Study, Act (PDSA) cycles that will help you make rapid change. The three fundamental questions for achieving improvements A planned approach to improving things will give you a better chance of success. The three fundamental questions for achieving improvement are a useful way of framing your work. 1. What are we trying to accomplish? This question is intended to help you be clear about the improvements that you would like to make, what results you would like to obtain and how you would like things to be different. Having a clear vision of your aims is crucial. 2. How will we know that a change is an improvement? Without measurement it is impossible to know whether you have improved. Think about how you want things to be different when you have implemented your change and agree on which data you need to collect to measure it. You can do this in terms of the way in which your results or outcomes might be different, how the services that your patients receive will be better, or how your processes might change. 3. What changes can we make that can lead to an improvement? Finally, you need to decide what changes you will try in order to achieve the results you are seeking. What evidence do you have from elsewhere about what is most likely to work? What do you and your team think is a good idea? What have other people done that you could try? This is where you can add patient ideas or be completely creative. Remember that you know your own system best, so keep your objectives in mind and use your knowledge and experience to guide you. Gather together as many ideas as you can. These will form the basis for the next step your PDSA cycles. Compiled by Townsville Mackay Medicare Local January

30 PDSA Cycles PDSA stands for Plan, Do, Study, and Act. Once you have decided exactly what you want to achieve, you can use PDSA cycles to test out your ideas developed from the third question, what changes can we make that will lead to an improvement? The key to PDSA cycles is to try out your change on a small scale to begin with and to rely on using many consecutive cycles to build up information about how effective your change is. This makes it easier to get started, gives results rapidly and reduces the risk of something going wrong and having a major impact. If what you try doesn t work as well as you hoped, you can always go back to the way you did things before. When you have built up enough information to feel confident about your change, you can then implement it as part of your system. Think of a small PDSA cycle in terms of the scope of your test. You might, for example, like to run your cycle over one day, with one person or in one clinic. You might wish to look at the last ten patients seen, the last twenty referrals made or the next dozen reports. The Study part of the cycle gives you the opportunity to reflect on what happened, think about what you have learnt and to build your knowledge for further improvement. Finally, you can move on to your next steps the Act part of the cycle. Do you need to run the same cycle again, gathering more evidence or making some modification based on what you learnt? Or do you need to develop further cycles to move your work forwards? Compiled by Townsville Mackay Medicare Local January

31 Practical Tips Improvement is nearly always a team endeavour. Try to ensure that you involve the right people in your work. People have a tendency to jump straight to solutions rather than really work out what the root of the problem is. If you use the three fundamental questions, it will help you to be sure that you are dealing with the issue that really needs to be addressed. When you plan your cycle, make sure you are clear about who is doing what, where and when. Your results are dependent on how good your plan is. Discuss what you think will happen when you try out your change. What is your hunch? When you have carried out the cycle, compare your expectations with what actually happened. You may learn something interesting about how things work. Record your PDSA as you go along: the plan, the results, what you learnt and what you are going to do next. Not only is it very motivating to see the results of what you have tried, it is also a great way of accumulating information about your systems and a good way of sharing your learning with other people. Use PDSAs consecutively to build up the information about your change and then use them to implement it systematically into your daily work. PDSA cycles generally do not operate in isolation you should expect to have a series of them leading towards your goal. Change Principles and Change Ideas Change Principles 1. Building the practice team 2. Establish a system for creating, validating and updating a register of people with diabetes 3. Be systematic and proactive in managing care 4. Involve patients in delivering and developing their care 5. Adopt a multi-skilled, multi-agency approach to ensure effective coordination of care Compiled by Townsville Mackay Medicare Local January

32 Change Ideas Change Principle 1: Building the practice team 1. Set goals 2. Engage the team 3. Assign roles & responsibilities 4. Communicate 5. Reflect & review Having an effective team is a necessary foundation on which to begin any quality improvement work. Attempting to implement change without appropriately engaging the practice team and assigning tasks is unlikely to lead to sustainable change. As a starting point, everyone in the practice should be aware of Chronic Condition Management, what changes are being tested; their specific roles in relation to implementing/testing change, and receive regular feedback on any data results the practice is achieving. Testimonial However the staff gets a great deal of satisfaction in seeing the improvements we have made with the patients outcomes. We were measuring less than 65% of our Hba1c when we commenced and are now measuring over 82% with 50% of all our diabetic patients have a HbA1c of less than 7%. Staff also enjoys being involved in the chronic condition management as it feels more like a team approach than general acute patients. The medical staff have gained more knowledge of these diseases as they have attended various teaching programs run externally such as those organised by the division or APCC and also internally with clinical meetings at the practice. We have achieved the goal we originally set by improving the care of the patients and the practices financial income. Paul Goulding, Practice Manager, Townsville and Suburban Medical Practice Compiled by Townsville Mackay Medicare Local January

33 Change Principle 2: Establish a system for creating, validating and updating a register of people with Chronic Conditions e.g. diabetes It is a good idea to start with one patient cohort when beginning chronic condition management. Many practices start with their Diabetes patients and then move on to other conditions. Chronic condition patients often have more than one condition but having a register allows you to know who your patients are and where they are up to in the care systems your practice puts into place. Change Ideas 1. Agree on a clear definition of diabetes for coding in Practice Software Diabetes type 1 is an autoimmune condition in which the body s own immune system destroys insulin-producing cells in the pancreas. Diabetes type 2 develops when the body is unable to produce enough insulin, or cannot use the insulin the body produce properly (insulin resistance). 2. Develop a register of people with diabetes An accurate, complete and current register of patients with diabetes type 1 and type 2 is the crucial starting point for improving diabetes care. If the practice has not already done so, it is suggested that they begin to construct the register by instigating a series of searches of their patient population. These could include searching for patients: Who have a diagnosis of diabetes recorded On insulin and/or anti - diabetic medications Who are on blood glucose monitoring or who have had a glucose tolerance test performed With an HbA1c recorded Patients who have previously had gestational diabetes, or have been diagnosed with impaired fasting glycaemia, or impaired glucose tolerance should also be reviewed to see if they have progressed to frank diabetes. Using a protocol for coding patient information can help to ensure consistency within the practice. Coding protocols used together with a diabetes template will improve data quality and consistency. Once the register is compiled, it should be distributed throughout the practice to check if any names have been left out. Compiled by Townsville Mackay Medicare Local January

34 Once the register has been established and validated, the next step will be to maintain its accuracy. This should include a system to ensure that new information on existing patients is gathered and recorded, and that new chronic condition patients are identified and included on the register. Here are some questions the practice needs to consider when developing systems for maintaining the register: 3. Develop systems to maintain a valid register Who will maintain the register? Could this person be formally recognised as the register manager? Would this person require training? How much protected times will this person need to maintain the register? How will new cases be identified? Where does the information come from? How will the practice ensure that the information reaches the register manager and is recorded and coded appropriately? How will the GPs in the practice notify the register manager of changes to patient information? Does the practice need a system to routinely check the quality of the information on the register? Does the practice need to document their system for maintaining the register so that things run smoothly when the register manager is away? Testimonial With a clean register you know how many patients have diabetes, CHD and you are ready to go. Using the tools you have, like diabetic register on MD and the Canning tool help identify the patients you need to see and what assessment needs to be done. Once you have identified the patients you can call them in to have a consult with the nurse. This immediately improves their outlook on their disease and they are more that happy to talk to you. We encourage a return visit in 6 weeks to check BP, do BSL and so on. The practice will be able to charge for this visit and you can call them back 5 times during the year. We have set it out at 6 weeks, first visit after GPMP & TCA, followed by review of TCA at 3 months, six weeks later another visit to see the nurse. We continue this way until the year is up. The major problem encountered was the staffing level. You need to have a nurse that is able to spend the time with the patient. We encourage our nurses to choose their patients, the ones that they feel they connect with and this will give the patient an anchor when ringing in with problems. We allocate a suitable time usually in the afternoon as we are busy in the mornings screening the patients, but time is flexible and suited to patients need. Marlene Griffiths, Practice Manager, Health & Wellbeing North Ward. Compiled by Townsville Mackay Medicare Local January

35 Change Ideas Change Principle 3: Be systematic and proactive in managing care 1. Establish clear practice arrangement Consider how the practice can establish arrangements for improving care for patients with chronic conditions and communicate that to all members of the practice team e.g. establish a small team to lead the work. Together this team would be responsible for developing and delivering the chronic condition care management system and ensuring that the system was agreed upon and communicated to all members of staff. 2. Establish systems for delivering care to patients with chronic conditions Establish practice protocols (or customise existing protocols) for the care of people with chronic conditions within the practice. Basing the practice s chronic condition care around agreed protocols means that the entire team is clear about roles, responsibilities and how patients are managed. Protocols need to be developed at the practice level to allow customisation for each individual practice and to ensure that members of the practice team are aware of their personal responsibilities within the system of care delivery. The practice will also need to ensure these are flexible enough to allow for changes and are reviewed when new staff are appointed. Compiled by Townsville Mackay Medicare Local January

36 Change Ideas (continued) 3. Establish proactive call and recall arrangements for people with chronic conditions Is the practice s existing call/recall system sufficiently proactive? Are patients invited for review at least annually? How do they track and follow up with patients who do not attend? How might the workload in the call/recall system be managed? Some practices find it useful to work out how many patients they need to see each year and have a system to call the right proportion each month or week, remembering to adjust that as the register grows. This allows a smoothing out of the demand for care, from groups of patients, throughout the full year and enables greater planning and control of the workload for the care team. Some practices find it useful to provide a general clinic to cover a number of chronic conditions e.g. asthma, diabetes, CHD. Can a member of the practice team be identified to manage the call/recall process? How will the practice call/recall patients? They may wish to use their clinical computer system (linking via their computerised diabetes template). Can a system be developed with the patients? How will the practice manage patients who do not attend? Is there a system in place to follow up patients in secondary care, especially diabetes type 1 patients? 4. Use guidelines, protocols and computer templates to support care delivery Embed the use of protocols through the use of manual or computerised templates. The use of computer templates allows a systematic, consistent approach to delivering care to patients and improved accuracy and completeness of patient data. Useful tips in maximising the use of templates are: Keep it simple and user friendly Provide one-to-one training and support to the health professional using the system Regularly use the data from the template to inform the team of its performance. Compiled by Townsville Mackay Medicare Local January

37 Change Principle 4: Involve patients in delivering and developing their care Change ideas 1. Maximise selfmanagement by people with chronic conditions The practice may want to consider developing/modifying their systems of care based on patient feedback. Patients should be able to provide valuable information on the style and content of letters and patient literature, the organisation and timing of clinics/appointments to maximise attendance, how to best deliver care to patients with more than one chronic condition, understanding issues around compliance with medication and developing patient self-care. The practice should consider the use of selfmanagement plans for people with chronic conditions and goal setting plans that have been agreed on with the patient. The aim of education for people with chronic conditions is to improve their knowledge and skills, enabling them to take control of their own condition and integrate self-management into their daily lives. It is suggested that patients should be involved in the decision making process for individually agreed targets to manage their chronic condition. It may be beneficial to utilise patient held records to enable this process to be more explicit. Patients who are better controlled are still put onto a GPMP or TCA if it s appropriate, but do so without the initial involvement of a dedicated clinic day. Patients on plans are regularly monitored through the use of the review item numbers and EPC nurse items numbers. We use checklists for each of the chronic conditions to ensure consistency of service to remind both the doctor and nurse of what tests of been conducted and when. Although we are continually tweaking our processes, we are now happy with the model we have. We faced a number of challenges during this period in getting the model to work well. To monitor patients on a chronic condition register and ensure they are regularly reviewed does take more resources than we had available. We have hired a Nurse (an EPC RN) whose sole duty is involved in Chronic Condition management. The EPC RN has her own dedicated consultation room and the assistance of a Nurse administrator to provide assistance to the EPC RN to reduce time spent on paper work and increase patient contact time. Paul Goulding, Practice Manager, Townsville and Suburban Medical Practice Testimonial Compiled by Townsville Mackay Medicare Local January

38 Change Ideas (continued) 2. Integrate the patient s perspective constantly in the design of services Involving and integrating the patient perspective into the design of services can be seen as a continuum from low to high user involvement as follows: Decisions publicised/explained before they are implemented Patients may take the initiative to influence decisions Patients views are sought before a decision is finalised Patients have the authority to selected decisions 3. Ensure written communication is appropriate and understood Most practices have written material (letters and advice leaflets) to support patient care. Some general practices are giving written chronic condition management plans to their patients. It may be useful to review patient education literature to ensure it is appropriate and clear. 4. Pay special attention to the needs of people from hard to reach groups It is obvious, but where possible pays special attention to people who have particular needs. Compiled by Townsville Mackay Medicare Local January

39 Change Principle 5: Adopt a multi-skilled, multi-agency approach to ensure effective coordination of the care of people with chronic conditions Change Ideas 1. Support joint working between health professionals and managers in practice/divisions and local state health services to enable integrated care for patients 2. Analyse the patient journey and redesign where necessary I am currently working as a designated Enhanced Primary Care Nurse at which I spend 4 days a week dealing with Chronic Disease Care Plans. I was initially very reluctant to take on this role, as I had minimal experience in this area. It has been a huge learning curve, but the doctors, other nurses and reception staff have been very supportive of this new role. Everyone has been pro-active in assisting me to help improve outcomes and support patients with Chronic Conditions. Initially we targeted Diabetes patients, but are now doing care plans for patients with Heart Disease, Osteoporosis and other chronic conditions. Being part of the Australian Primary Care Collaboratives has helped us to target areas we needed to improve in, not only for the patients but also for the practice to deliver better quality of care. It has taken some time but I feel we are finally seeing benefits from the care plans. Patients are now actively ringing the practice if we haven t booked them in for a review. Plus with the collaboratives we have been able to measure outcomes and really see improvements, such as more than 50% of all our Diabetes patients now have a HbA1c of less than 7%. We have also started working more intensively on getting our Diabetes patients blood pressures to target and at present have 44.2% <=130/80. Anna Thompson RN Enhanced Primary Care Nurse, Townsville and Suburban Medical Practice. Testimonial Compiled by Townsville Mackay Medicare Local January

40 PDSA CYCLE EXAMPLES 1. Change Principle: Be systematic and proactive in managing care Objective: To improve the completion of the annual cycle of care for diabetes patients PLAN PN to audit the diabetes register to determine how many patients have not completed their annual cycle of care. Task to be completed by the end of the week. DO Audit completed STUDY 280 patients were identified as needing to be recalled ACT As there are a large number of patients, the clinic will send out 4 letters/week. This will ensure the clinic is not overloaded and same day access is not taken up. Patients will see PN first to complete the major part of the assessment before review with GP. (Example from National Primary Care Collaborative) 2. Change Principle: Build the practice team Objective: To determine how the practice was going to participate in the collaborative program PLAN Meeting with all practice staff to assign various tasks and discuss how to implement collaborative activity. Meeting next Tuesday. DO Meeting held STUDY Discussion held and tasks identified ACT Dr X and Senior admin to advance improvements, PM to look at monthly measures, admin to inform all of staff of PDSAs and any system changes (Example from National Primary Care Collaborative) Compiled by Townsville Mackay Medicare Local January

41 Example PDSA PLAN DO STUDY ACT Topic Change Principle Description What idea do you want to test Plan What, who, when, where, predictions & data to be collected Do Was the plan executed? Document any unexpected event or problems Study Review and reflect on results Act What will you take forward from this cycle (Example taken from the Improvement Foundation Australian Primary Care Collaborative (APCC) program) Photocopy and use as template. Compiled by Townsville Mackay Medicare Local January

42 Quality Improvement & Continuing Professional Development Program triennium Quick guide to the rapid PDSA cycle of quality improvement The plan, do, study, act cycle It is important that GPs and the general practice team participate in quality improvement in such as way that will contribute to improved safety and care outcomes for patients and make positive changes to practice systems, processes and structures. In the triennium, a minimum of three rapid plan, do, study, act (PDSA) cycles must be completed within a 3 month period to gain 40 Category 1 points. The PDSA cycle uses simple measurements to monitor the effects of change over a period of time. It encourages starting with small changes, which can quickly be built into larger improvements, through successive cycles of change. It emphasises starting unambitiously, reflecting and building on learning. It can be used to test suggestions for improvement quickly and easily, based on existing ideas and research, or through practical ideas that have been proven to work elsewhere. Three main questions underpin the PDSA cycle: 1. What are we trying to accomplish? 2. How will we know that a change is an improvement? 3. What changes can we make that will result in improvement? Plan Objective What? Who? When? How? Study Analyse Compare results to expectations Summarise what was learned Do Carry out the plan Document observations Record data Act Act on results Refine the plan Compiled by Townsville Mackay Medicare Local January

43 P plan the change What do you want to achieve, what actions need to happen and in what order? Who will be responsible for each step and when will it be completed? What resources are required? Who else needs to be kept informed or consulted? How will you measure changes to practice? What would we expect to see as a result of this change? What data do we need to collect to check the outcome of the change? How will we know whether the change has worked or not? D do the change Put the plan into practice and test the change by collecting the data. It is important that the do stage is kept as short as possible (although there may be some changes that can only be measured over longer periods). Record any unexpected events, problems and other observations. S study Has there been an improvement? Did your expectations match what happened? What could be done differently? A act on the results Make any necessary adaptations or improvements, acknowledge and celebrate success. Collect data again after considering what worked and what did not. Carry out an amended version of what happened during the do stage and measure any differences. Compiled by Townsville Mackay Medicare Local January

44 Criteria for undertaking rapid PDSA cycles Practice cycle A practice PDSA cycle is defined as an activity that focuses on improving the capability of the practice to deliver on quality patient care. It should improve the quality, safety and performance of the practice (ie. meeting RACGP standards, and improve systems, process and/or procedures). A practice PDSA cycle may be undertaken by an individual GP, a group of GPs, and/or a multidisciplinary team. A whole of practice approach to quality improvement is encouraged. Assign a facilitator A maximum of 10 participants May be conducted face-to-face, via teleconference or as an online group a mixture of technology may be used A minimum of three PDSA cycles must be completed within a 3 month period to gain 40 Category 1 points Completion of online activity notification Individual cycle An individual PDSA cycle is defined as an activity that focuses on improving the individual GP s clinical performance, clinical knowledge and/or skill. A minimum of three PDSA cycles must be completed within a 3 month period to gain 40 Category 1 points An online activity notification must be completed. Steps for undertaking rapid PDSA cycles Practice cycle 1. Select a leader/facilitator and decide who will be in the PDSA group 2. Discuss the following questions: What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that can lead to an improvement? 3. Select a topic 4. Conduct three PDSA cycles, ensuring an online self reporting activity notification is completed. Individual cycle 1. Discuss the following questions: What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that can lead to an improvement? 2. Select a topic 3. Conduct three PDSA cycles, ensuring an online self reporting activity notification is completed. Examples of PDSA cycles Individual PDSA cycle The following outlines how an individual GP may make improvements to patient care, using one or more PDSA cycles. Cycle 1 Plan: Identify the problem. Analyse the problem The latest routine patient satisfaction survey has identified some negative patient responses in the area of patient-physician communication. Comparison from results of previous surveys and those of peers within the practice suggests the results are likely to be statistically significant and indicative of an opportunity for improvement. Do: Develop solutions. Implement solutions Undertake a therapeutic counselling/listening course. Implement aspects of learning within day-to-day practice for defined period. Alternatively, reflect on current communication style and identify and implement areas for improvement, eg. ensuring patient has opportunity to explain. Compiled by Townsville Mackay Medicare Local January

45 Study: Evaluate the result Conduct further a patient survey for a previously defined period and evaluate the results. Act: Standardise the solution. Capitalise on new opportunities Reflect on communication outcomes. Confirm or revise individual communication protocols. Possible Cycle 2 Plan: Identify the problem. Analyse the problem For some patients with complex and/or multiple issues, a standard consultation does not allow enough time to provide for more than cursory communication between GP and patient. Do: Develop solutions. Implement solutions Develop a system to identify and implement a system to ensure that those patients requiring extended consultation receive extended consultation. Study: Evaluate the result Conduct a further patient survey for a previously defined period and evaluate the results. Act: Standardise the solution. Capitalise on new opportunities Continue to monitor patient satisfaction and capacity for extended consultations where required. Continue to look for further improvement opportunities. Practice PDSA cycle Practices are most suited to the application of PDSA cycles. The following examples provided by the Institute of Healthcare Improvement describe a PDSA approach to improving diabetes care, applicable to practice teams. Cycle 1 Plan: Identify the Problem. Analyse the problem Select an initial diabetes treatment regimen. Do: Develop Solutions. Implement solutions Teach the patient to implement the regimen and to monitor their blood glucose values. Study: Evaluate the result Review the patient s self monitoring of blood glucose (SMBG) values at follow up clinic visits: note where values have improved note where values fall outside of the desired range. Review the follow up A1c value. Note change in the value compared to the baseline value. Act: Standardise the solution. Capitalise on new opportunities Based on results of the SMBG values, adjust the treatment regimen to: maintain the improvement over the baseline value obtain further improvement in glycaemic control. Evaluate how to adjust the treatment regimen: change in meal plan change in physical activity change in medication/insulin regimen. Select a single intervention and test it through another PDSA cycle. Cycle 2 Plan: Identify the problem. Analyse the problem Select an initial diabetes treatment regimen. Do: Develop solutions. Implement solutions Teach the patient to implement the regimen and to monitor their blood glucose values. Study: Evaluate the result Review the patient s SMBG values at follow up clinic visits: note where values have improved note where values fall outside of the desired range. Compiled by Townsville Mackay Medicare Local January

46 Review the follow up HbA1c value. Note change in the value compared to the baseline value. Act: Standardise the solution. Capitalise on new opportunities Based on results of the SMBG values, adjust the treatment regiment to: maintain the improvement over the baseline value obtain further improvement in glycaemic control. Evaluate how to adjust the treatment regimen: change in meal plan change in physical activity change in medication/insulin regimen. Select a single intervention and test it through another PDSA cycles. Continue rapid cycle improvement until: management goals are reached adverse response to intervention/s precludes further improvement. Examples of PDSA cycles linked to RACGP Standards Individual GPs and practice teams may save time and resources by undertaking a PDSA cycle linked with the current standards for GPs documented in the RACGP Standards for general practices 3rd edition, thus simultaneously meeting elements of practice accreditation and the mandatory quality improvement component of their QI&CPD. A number of examples of PDSA cycles are provided below: Example 1 Standard criterion 1.1.1: Scheduling care in opening hours The issue is to efficiently and effectively accommodate patients with urgent, nonurgent, complex, planned chronic care, and preventive health needs. This example looks at how a practice might use several PDSA cycles to improve a number of aspects of patient scheduling, beginning with the aspect that would appear to present the most risk, that of ensuring urgent patients are seen quickly. Cycle 1 Plan: Identify the problem. Analyse the problem To ensure that urgent patients are seen as soon as appropriate. Do: Develop solutions. Implement solutions Develop a triage protocol including checklist for practice staff to identify urgent patients who either attend the practice or call for an appointment. Create protocol that includes under what circumstances an ambulance is called. Train practice staff. Study: Evaluate the result Record details of urgent visits including numbers, time taken to treat patient, and other notable aspects of the treatment episode. Act: Standardise the solution. Capitalise on new opportunities Reflect on episode/s of care provided. Confirm or revise protocols. Cycle 2 Plan: Identify the problem. Analyse the problem Ensure patients with chronic disease or those with complex needs have access to extended consultation. Do: Develop solutions. Implement solutions Undertake data collection to identify numbers of chronic and/or complex patients. Study: Evaluate the result Conduct an audit of appointment book. Gather data on appointments not filled/unused surgery time. Act: Standardise the solution. Capitalise on new opportunities Ensure each surgery has capacity in appointment schedule for chronic patients if required. Cycle 3 Plan: Identify the problem. Analyse the problem Ensure non-urgent patients are seen in a timely manner. Compiled by Townsville Mackay Medicare Local January

47 Do: Develop solutions. Implement solutions Determine acceptable standard for scheduling of non-urgent patients, eg. to be seen within 2 working days. Study: Evaluate the result Collect data on timeliness of appointments for nonurgent patients. Match this data against practice capacity shown from appointment book audit data collected in Cycle 2. Act: Standardise the solution. Capitalise on new opportunities Depending on the results: continue to monitor scheduling and/or increase operating hours and/or hire more GPs and/or practice staff and/or limit patient list. Example 2 Standard criterion 1.4.1: Evidence based practice The issue is that tobacco smoking is responsible for the deaths of approximately Australians each year. 1 There are 10 major risk factors to which the disease burden can be attributed in Australia, tobacco smoking causes an estimated 10% of the total disease burden. 2 Evidence exists that general practice can make a significant difference in smoking cessation. This example looks at how a practice might use several PDSA cycles to increase the rate of smoking cessation of patients. (A practice may first wish to prioritise its focus on a category of patients such as pregnant women or those with chronic illness before including all patients.) Cycle 1 Plan: Identify the problem. Analyse the problem First cycle requires identification of smoking status of all patients (over 10 years of age). Do: Develop solutions. Implement solutions Develop a system to record status (in conjunction with practice team). Use smoking status terms such as current smoker, former smoker, never smoked. Brief the practice team on recording requirements. Study: Evaluate the result Evaluate success of identification. Select a time frame and tally the percentage of patient files with smoking status recorded. Remind and encourage staff if necessary. Act: Standardise the solution. Capitalise on new opportunities GP records smoking as active health issue in relevant patient files. Cycle 2 Plan: Identify the problem. Analyse the problem To assist smokers to quit using 5A guidelines. Do: Develop solutions. Implement solutions Clearly advise the smoker to stop. Assess patient interest in quitting. Prescribe/recommend appropriate pharmaceutical products for nicotine addiction. Refer to external supports such as Quitline. Study: Evaluate the result Assess success of interventions. Act: Standardise the solution. Capitalise on new opportunities Focus on relapse prevention. Use a reminder system to encourage quitters to attend appointments focused on quitting/relapse prevention. Reinforce the positives of quitting. Continue to encourage. Compiled by Townsville Mackay Medicare Local January

48 Cycle 3 Plan: Identify the problem. Analyse the problem To increase the success of smoking cessation interventions across the practice. Do: Develop solutions. Implement solutions GP to brief/train fellow GPs and/or practice staff in 5A approach. Source up-to-date resources to assist cessation. Place relevant information/posters or other materials in prominently located locations within the practice. Study: Evaluate the result Continue to collect and monitor practice data on smoking/cessation. Act: Standardise the solution. Capitalise on new opportunities Practice to continue to apply 5A technique to assist patients to quit. Continue to identify patient smoking status for new patients. Seek regular updates/subscribe to smoking cessation tools/information. Additional quality improvement tools and resources, along with these and other examples of PDSA cycles linked to RACGP Standards for general practices are located at au/standards. Compiled by Townsville Mackay Medicare Local January

49 Clinical audit (40 Category 1 points) Research into evidence based medicine shows that a clinical audit is more likely to result in changes in GP behaviour and improvement in practice than traditional didactic medical education methods. As a quality improvement tool, clinical audit is supported by research evidence. Individual GPs, groups of GPs or education providers can develop clinical audits. Education providers who develop clinical audits can advertise to recruit individual GPs to participate in their clinical audits. Many ready made clinical audits are provided by various groups such as divisions of general practice, universities and the RACGP. Practice based groups are encouraged to develop clinical audits to investigate issues of relevance to their practice. Individual GP and small group clinical audit forms are available on the RACGP website to assist with development. Alternatively GPs and practices can contact their state faculty QI&CPD unit for advice. A clinical audit compares actual clinical practice against established standards of practice and while it is not the same as research it still may require approval from the RACGP Human Research Ethics Committee (HREC) or other ethics committees constituted under the National Health and Medical Research Council (NHMRC). If the provider intends to publish audit outcomes, or where a very large number of patient details are collected, or where details of a potentially identifying nature are collected, the audit developer may be advised to seek HREC approval before the audit application. The QI&CPD Program reserves the right to require audit developers to seek HREC approval. For more information in relation to ethics, please see the GP research section of this handbook (pages 17 20). There is more detailed information on privacy at the website of the Australian Government Office of the Privacy Commissioner ( In the context of the QI&CPD Program, a clinical audit is a planned medical education activity designed to help GPs systematically review aspects of their own clinical performance in practice against the criteria set out below. A clinical audit has two main components: an evaluation of the care that an individual GP provides a quality improvement process. Compiled by Townsville Mackay Medicare Local January

50 Criteria An audit can be undertaken by an individual GP or in a small group with a minimum of two GPs and a maximum of 12 participants. Small group clinical audits with more than 12 participants must discuss their individual needs with their state faculty QI&CPD Program coordinator Data may be collected and collated online or be paper based. Feedback mechanisms vary and may be face-to-face, online or via paper based methods Clinical audits can either be of fixed time duration or based on patient numbers, depending on the prevalence of the condition or the audit topic, eg. if presentation is quite rare, the audit may continue for more than 1 year. Other audits are structured around patient numbers, which may include large numbers over a short period of time A description of the clinical audit and what it involves needs to be provided A statement of GP learning needs is needed Information on how many patients will be audited and how they will be selected is needed How privacy, confidentiality and consent will be addressed should be documented Whether HREC approval is required should be ascertained The five steps of the audit cycle must be completed. Steps in the clinical audit cycle module 1. Conduct a needs analysis identify valid educational needs, clinical audit objectives and list references 2. Identify standards list best practice guidelines, develop clinical audit criteria, identify your standards and list references 3. Data collection and analysis collect data, complete informed participant consent, compare data against standards, reflect on results 4. Identify and implement change reflect on results and document proposed changes to practice with the consideration of reliably enhancing patient safety 5. Monitor progress evaluate changes, write final report identifying any improvement in patient outcomes and submit record of participation. Clinical audit examples Small group clinical audit radiology in a rural practice The content of medical presentations to many rural GPs often includes patients with trauma. In rural practices radiologists are not always in close proximity to be able to interpret X-rays, and as a consequence it is valuable for rural GPs to be skilled in the interpretation of radiology. In order to maintain expertise and competency in analysing radiographs, and to ensure the ongoing safety of their patients, a group of GPs develop a small group clinical audit to improve their interpretation of X-rays. The aims of this small group clinical audit are to: improve GPs skills and competency in analysing radiographs increase the number of radiographs that are correctly analysed in a 12 month period. Standard An expert radiologist gives diagnosis on X-ray that has filmed: persistent chest symptoms or significant chest signs exposure to asbestos or other noxious chemicals significant trauma to face, head and neck. The way in which the audit is conducted is that once the radiologist has provided his/her own report it is forwarded to the referring GP. Before the GP reads the radiologist report, the GP proceeds to make his/her own diagnosis. The GP completes an audit sheet, which is recorded in an excel spreadsheet to enable comparison between the radiologist report and the GP report. Any reports with radiological discrepancies are followed up and discussed at a monthly review. To improve the skills of the GP, this quality review process is repeated at quarterly intervals for 12 months. This provides the GP with an opportunity to reflect on their progress and identify areas for further development. The audit group discuss mechanisms to maintain standards of interpretation and decide to have an interesting case presentation at their monthly clinical meeting. Compiled by Townsville Mackay Medicare Local January

51 Provider clinical audit for GP participants chlamydia trachomatis A sexual health organisation conducted a needs analysis (Step 1) and identified that Chlamydia trachomatis is the most common notifiable sexually transmitted infection (STI) in Australia. Chlamydia is a leading cause of pelvic inflammatory disease and tubal infertility with over 65% of all infections being diagnosed in women aged years. The majority of women with the infection do not have any symptoms and can only be identified through screening. The aim is for GPs who participate in this activity to: become more aware of chlamydia infection and other STIs their prevalence in the community and their clinical presentation be able to identify women who are appropriate to be tested for chlamydia infection develop skills to discuss chlamydia and other STIs with patients, particularly young women. Clinical audit criteria Standard Data to be collected (Step 3 and 4) All sexually active women aged years are encouraged to have chlamydia testing Ideal: up to 100% Acceptable: more than 25% Patient s age Patient s eligibility for a chlamydia test Previous history of a chlamydia test Note: All data will be aggregated Participating GPs are informed of their chlamydia testing rates and how they compare with other GPs participating in this clinical audit. Comparisons between the RACGP Guidelines for preventive activities in general practice, 6th edition ( red book ) recommendations and screening rates in comparable countries is also analysed. General practitioners are given the opportunity to reflect on their practice and consider what systems they can adopt in their clinics to ensure women are reliably and appropriately identified for chlamydia testing. Step 5 of this clinical audit is monitoring progress (which involves repeating Step 3 and 4) 6 months later. In this phase, the GP reviews any system changes in the practice and measures improvement in patient outcomes as a result of changes made from participating in this audit. Compiled by Townsville Mackay Medicare Local January

52 Small group learning (40 Category 1 points) Small group learning (SGL) is designed to assist GPs to maximise the benefits of working and learning together in a small group educational setting. Participants initially meet to determine their goals or learning objectives and plan a series of sessions to achieve these goals. Learning is encouraged through sharing and collaboration. At the end of each cycle, the group reflects upon what was learnt, how the group functioned, the benefits of the small group process and how this might be improved in any future activities. Small group learning can include other health professionals who utilise peer support, interaction and reflection to enhance their own clinical competence (ie. knowledge, skills, attitudes) and performance. Although the focus of the small group is on learning, the importance of team building in terms of joint responsibility in practice is strengthened. Small groups are an ideal format for GPs to share their knowledge and discuss their daily practice with peers. The direction of the group is often determined by the group as a whole. A skilled facilitator that assists the group to stay focused deals with group dynamics effectively and allows participants to take ownership of the process, which often results in members having a positive and rewarding learning experience.9 Evidence shows that when learners have the opportunity to select topics relevant to their own practice and measure their practice against that of their peers, motivation is high and more likely to enhance change in clinical practice. The literature suggests that for small groups to be most effective they should: build on prior knowledge and experience relate to the perceived learning needs of participants actively involve learners through group work, discussions, practical tasks and problem solving focus on problems that are either derived from participant experience or created by facilitators be immediately applicable in practice relevant, realistic and consider participant s primary care context involve cycles of action and reflection which assist to consolidate learning and may take place within the group or outside or both allow the acquisition of technical skills through observation, simulation or practice of technical skills have an effective facilitator engender a positive group atmosphere and promote adherence to small group goals integrate with clinical practice promote critical thinking and problem solving. Small groups can also perform group audits these audits have proven to be a positive experience for participants and have assisted significantly in standardising records in order to improve systems to identify more patients. For instance, one small group who conducted an audit identified that 30 50% of regular checks were not being performed. The group then changed practices so the audit assisted in standardising records and improving systems to identify more patients. A key for the triennium is for small groups to consider how practice systems can contribute to the maintenance of the improvements they identify and discuss. Criteria A minimum of four and a maximum of 10 participants including a minimum of two GPs. Other members of the practice team or interested people may participate (eg. the practice nurse, specialist, psychologist, teacher). Small groups with more than 10 participants must discuss their individual needs with their state faculty QI&CPD Program coordinator Ideally someone will accept responsibility for organising the group, however, the group may decide to share responsibility It is preferable for each small group to have a facilitator The group may be conducted face-to-face, via teleconference or as an online group a mixture of technology may be used The group should register with their state faculty QI&CPD unit before starting a cycle Compiled by Townsville Mackay Medicare Local January

53 A minimum of 6 hours meeting time must be completed by all members for each SGL cycle in order to obtain Category 1 points The duration of each meeting must be a minimum of 1 hour Planning and review meetings, meals, drinks and other social activities or networking outside of educational content should not be included in the minimum 6 hours The cycle may be completed over a short period, but may also span over the 3 years of the triennium, depending on the needs of participants The group may define its own content and agree to undertake a program of activities Each group must define learning objectives, including one learning objective on systems in the practice for each cycle The group should outline key learning outcomes achieved Once the group has completed a cycle, including conducting a review meeting, each participant must sign a review form and submit to their state faculty QI&CPD unit. Steps in the small group learning cycle module 1. Identify 4 10 interested participants a minimum of four and a maximum of 10 participants including a minimum of two GPs. Existing groups can re-register to participate in more than one cycle in the triennium 2. Identify a group facilitator and someone to organise the group facilitators are encouraged to undertake facilitator training and keep a facilitator s reflective diary 3. Each participant agrees to identify and reflect on his/her personal learning needs in relation to this group before the meeting 4. Hold an orientation and planning meeting review the issues and options for the group and develop a program of CPD activities (topics, dates) 5. Complete a small group registration form and send to your state faculty QI&CPD unit 6. Undertake the program of CPD activities 7. Hold a review meeting at the end of the cycle to reflect on the outcomes of the group 8. Complete a small group review form and send this to your state faculty QI&CPD unit. For the forms to complete these programs go to: Websites Quality Improvement Australian Primary Care Collaboratives Practice Improvement RACGP Forms and Guides Compiled by Townsville Mackay Medicare Local January

54 A Guide to Chronic Condition Management Part 4 Managing Patient Information in General Practice Inside this section Patient Information Management 96 Data Extraction Tools Pathology Results in Practice Management Software 101 Coding in Practice Management Software Recording Data in Practice Management Software 105 Other Actions for validation of Patient Information Recall Systems Templates 109 Websites 110 Compiled by Townsville Mackay Medicare Local January

55 Patient Information Management Introduction Medical software programs currently used in general practice are excellent for information storage and retrieval on a patient by patient basis. However, most programmes have limited or difficult to use capabilities in regard to retrieval of information for the entire patient population. This makes them generally too difficult to use for systematic management of patients. As a result of this a number of companies have designed computer programs (data extraction tools) that enable you to extract patient population information from your individual practice management systems. This gives the practice a way of looking at the information to enable quality improvement and clinical decisions for a range of different patient populations within the practice. Data Extraction Tools Diabetes Coronary Heart Disease Asthma Examples of Extractions include: Individual diseases Prescribing Pap Smears Income Estimator Tracking of SIP payments (Diabetes Annual Cycle of Care) Prevention Areas Fluvax, Pnuemovax, Risk of Diabetes Compiled by Townsville Mackay Medicare Local January

56 DATA EXTRACTION TOOLS 1. Canning Data Extractor Tool The Canning division decided to develop its own data extraction capability in early When the National Primary Care Collaboratives was launched in Australia in late 2005, the NPCC (now called APCC) approached Canning Division with a request to develop a data extraction tool for the Collaboratives project. The tool extracts clinical data for patients with diabetes, coronary heart disease (CHD) and Chronic Obstructive Pulmonary Disease (COPD). Canning Division now produces a range of tools which are capable of extracting data from a variety of the most commonly used GP desktop software. Including: Medical Director 2 Medical Director 3 Best Practice PractiX MedTech32 The Canning Data Extraction Tool is available free of charge to Townsville practices through the Townsville - Mackay Medicare Local. The total population de-identified data and chronic condition measures e.g. HbA1c and total cholesterol for diabetes patients is sent to TMML at the end of every month and a graphed and summarised report is sent back to the practice. A Practice Agreement is signed by the practice to enable this process. Compiled by Townsville Mackay Medicare Local January

57 2. TMML Data Extractor The software tool developed by TMML includes the following functionality: 1. Allows the practice to generate a diabetic register 2. Allows the practice to identify undiagnosed patients who have a high likelihood (but not a certainty) of being diabetic based on drugs they have been prescribed or an HbA1c result suggestive of diabetes. 3. Produce graphs on how many patients have measures (HbA1c, BMI, BP, cholesterol, ACR) within the normal range over the last 12 months 4. Extract data on processes, specifically use of EPC items for GP Management Plans, Team Care Arrangements and Diabetes Cycle of Care and HMRs. 5. Extract data as Excel spreadsheets that can be used by the practice and also ed to TMML. This is core data on HbA1c, BMI, BP, cholesterol, ACR, use of EPC item numbers. This information will be used by TMML to produce reports that can then be used by the practice to inform decision making in relation to changes (if required) to current systems regarding diabetes. This data extractor is compatible with: Medical Director 3 Practix 3. PEN Clinical Audit Tool The CAT can assist practice staff to assess the quality and completeness of patient information, and therefore practice population information, while highlighting opportunities to increase income from Practice Incentive Payments (PIPs). CAT is not just a reporting system. It is a clinical information system that allows the GP and practice staff to target patients with particular needs or those with specific health risk profiles. CAT will support the requirements of divisional initiatives such as the Australian Primary Care Collaboratives (APCC) and the National Performance Indicators (NPIs). This data extractor is compatible with: Medical Director 3 Medical Director 2 Genie Best Practice Compiled by Townsville Mackay Medicare Local January

58 4. Doctor s Control Panel The DCP uses a set of configurable rules to determine whether prompts are shown and uses information in the database to determine status. The DCP also allows printing of data collection sheets and Action lists for the day s appointments. This allows staff to implement the data collection, which the doctor can simply enter into software at consultation. The DCP also creates reports on basic statistics. The benefits of using the Doctor s Control Panel include: Improved coherence with Red Book Guidelines particularly BP, Height, Weight and Waist Measurement Encourages the practice to utilize electronic recording of measurements within the clinical software Increased utilization of preventative care MBS items and thus increased billings of these items Figure 1. Screen Shot of the DCP popup panel which appears above the tray area of the desktop. Shows some of the range of prompts available. Headings are blue; items are coloured red if not done, yellow if overdue for repeating and green if up to date. Prompts are tailored to the individual patient. DCP is compatible with Medical Director 3 only and is free to download from Compiled by Townsville Mackay Medicare Local January

59 Primary Care Sidebar The PrimaryCare Sidebar delivers a standard e- health resource onto the computer desktops of primary care providers. Providing a range of valuable clinical tools and resources at the fingertips of clinicians, the PrimaryCare Sidebar eases existing work flows while facilitating the delivery of best care for patients. PrimaryCare Sidebar sits alongside the clinical desktop system and can pull through information from the open patient record *. This means that decision support, assessments and other tools that support chronic disease prevention and management are always at hand. Currently on offer: eredbook eassessments Australian Medicines Handbook Clinical Audit Tool Prompts Over time, the e-health product offering will expand to also include applications which facilitate secure electronic collaboration for care teams, provide access to a range of health delivery guidelines, and help GPs respond to insurance requests and other. Websites Quality in Practice - AGPAL Information Management Canning Data Extraction Tool Pen Computer Systems Primary Care Sidebar Compiled by Townsville Mackay Medicare Local January

60 PATHOLOGY RESULTS IN PRACTICE MANAGEMENT SOFTWARE Pathology Download Format: The extraction tool will only find pathology results that are embedded in the patient record. Electronic transfer of results comes in two different formats.pit and HL7. To ensure the appropriate blood test results are in a suitable format for extraction, please request from all pathology providers, that your tests are being downloaded in HL7 format. This will ensure they are included on your register and in the measures. In the Diabetes Record, if you have HL7 downloaded results you will notice the values for cholesterol, HbA1c and microalbumin are already populated. You can also request from your pathology provider/s that they re-download cholesterol and HbA1c results for the last 12 months. This could be done for 2 reasons: To ensure you register contains the most up-to-date patient information as possible so you may easily identify who has blood test results missing To identify any patients who have had the requested tests but were not coded as having Diabetes, nor prescribed medication, and therefore excluded from the register HL7 - What is it and why it matters? HL7 is a messaging protocol. It is used to transfer messages and test results between pathology labs, doctors and hospitals. The reason HL7 is a desirable format for this sort of data exchange is that it has the capacity to atomise data into discrete pieces. Software can then be instructed to handle these pieces intelligently. The most useful example of this for GPs lays in the treatment of incoming pathology test results. If they are delivered in HL7 format and they contain numerical results, the numerical data can be copied to the fields in the database where they belong. This saves time and drastically improves chronic disease management. Pathology labs have the capacity to deliver HL7 results now, but often need to be asked to make the change from the older PIT format to HL7. They do not charge for this change over. Practices who believe they are receiving data in HL7 format already can verify it by checking that recently processed results have been transferred to the correct database fields. E.g. is a recent HbA1C result visible in the HbA1c field in the clinical software? While HL7 works with HbA1c and cholesterol, it does not work with Pap smear data. An additional step needs to undertaken in practices so that Pap smear data is picked up by any data extraction tool. The result shown in the pathology report needs to be individually transferred to the Pap smear fields. CODING IN PRACTICE MANAGEMENT SOFTWARE After creating your chronic condition register you will need to validate it (make sure it is accurate) and keep it that way. The following activities are some ways of validating your register: 1. Inactivating patients Information that is no longer relevant should be archived, otherwise it clutters up your system and sustainable improvements will be very difficult to achieve. The practice s register of patients should therefore be kept current. Until recently, most clinical packages did not allow practices to bulk archive their patients. This meant that data cleaning was a more labour intensive process than really necessary. At least three clinical packages (MD3, Best Practice and PractiX) now allow bulk archiving of patients. This means that the practice can decide on a certain rule (e.g. inactivate all patients who have not visited the practice in the last two years) and inactivate their patients accordingly. Compiled by Townsville Mackay Medicare Local January

61 2. Decide what constitutes a regular patient Before proceeding, please decide collectively as a practice what constitutes a REGULAR patient. In many cases, this will be 2 or 3 years, as an example. This decision lies with the practice. How to inactivate or mark a patient as deceased: This applies to: Deceased patients Patients who have left practice Inactive patients Visitors to the practice/transient patients IMPORTANT Please ensure all staff are informed and trained in the correct process for identifying and inactivating all of the above. This will ensure your database remains current. Use your Diabetes and CHD Data lists (from the extraction tool if you have one) to go down the list of patients on the register. There will be patients on the register who may not have attended for the timeframe you have identified as outside the definition of a REGULAR patient. These will need to be inactivated in your system. The practice should make it a priority and have a system in place to actively cull records. All Staff at the practice may be involved in this process of verification. 3. Decide on uniform codes to be used for Diabetes & CHD (and then other chronic conditions) Problems can exist with disease coding when the incorrect code is used (GPs free typing own codes instead of using the software code). It is important to have a staff meeting involving all doctors and nurses and decide what codes are to be used for which conditions. For the patient to be included in the register, they must have a coded diagnosis in Past Medical History. For example: Diabetes Mellitus Type 1 and Diabetes Mellitus Type 2 IHD Please ensure all myocardial infarctions are coded with a diagnosis date Uncoded or free-texting of diagnoses is problematic with establishing and maintaining a register as your system will be less efficient and accurate than it should be. All Doctors should use these uniform codes routinely. Any additional information can be entered into comment section directly under the diagnosis component. 4.Perform database search on all diagnoses for Diabetes & CHD (and then other chronic conditions) Diabetes The reason for doing these searches on your clinical software is to verify that all your patients with diabetes are found. This ensures that they are included in your Diabetes Register from the extraction tool. You may also want to add a date range to your search e.g. seen within the last 2 years. Perform database search on all diagnoses for Diabetes & CHD Diabetes Coronary Heart Disease IDDM Coronary Heart Disease Diabetes Mellitus Type 2 Myocardial infarction Diabetes Angina Diabetes controlled Angioplasty Diabetes unstable Ischaemic Heart Disease Diabetes with Vascular Changes CABG Diabetic Endarteritis Diabetic Peripheral Vascular Disease Compiled by Townsville Mackay Medicare Local January

62 To streamline the identification and cross-checking process, please ensure (if software permits), you enter a date restriction when database searching. This will provide a more current list of patients who have attended the surgery. It may also include deceased patients, visitors and patients who have moved on these patients will need to be identified and inactivated. Coronary Heart Disease (CHD) A data extraction tool will identify all patients in your clinical software who have a coded diagnosis of the above list. It will not find patients who DO NOT have one of these diagnoses coded. The reason for doing these searches on your clinical software is to verify that all your patients with CHD are found. This ensures that they are included in your CHD data listing from the extraction tool. The easiest way to find this group of patients collectively is to assign all patients with one of the above diagnoses with an umbrella diagnosis of Ischaemic Heart Disease (IHD) in the past medical history if your software doesn t have ICPC coding already. This will assist you to quickly identify these patients in the future when you are trying to search for specific items relating to your CHD patients. 5. Perform database search for all drug classes Conduct searches in your clinical software to search for all patients with an uncoded diagnosis of diabetes and CHD (and then other chronic conditions) Commonly used drug classes in Diabetes and CHD Diabetes CHD Metformin* Atorvastatin Glibenclamide Fluvastatin Glimepride Pravastatin Gliclazide Simvastatin Glyade Asasantin Glipizide Vytorin Repaglinide Or search HMG-co-A reductase inhibitors for all statins Acarbose Pioglitazone Rosiglitazone Insulin (Refer extraction tool (if you have one) settings for comprehensive list) *Please note that Metformin will also identify patients with Gestational Diabetes and Polycystic Ovarian Syndrome (PCOS). Please exclude these patients for a Diabetes register. Alternatively, you can search for: Anti-diabetic agents Hypoglycaemic agents Insulin Searching for individual diabetic drugs is not necessary in Medical Director. MD has the capacity to search for a class of drug. Coronary Heart Disease (CHD). This will find all people prescribed this medication, which do NOT have a coded diagnosis of IHD. A GP will need to go through the list and identify those patients who should be on the CHD register (not all people identified in this search will have CHD). Add the primary diagnosis (Angina, MI, Angioplasty, and CABG) and also add IHD to the past history and include the year of primary diagnosis. Alternatively, you can search for: Antiangina Antihypertensives Lipid reducing agents Compiled by Townsville Mackay Medicare Local January

63 Pap Smear Recording Cervical cancer is one of the most preventable cancers in women and approximately 90% of the most common (squamous cell carcinoma) can be prevented by Pap smear screening every 2 years. (The health of Queenslanders 2010) The responsibility for this falls mostly on General Practice. While General Practices in have very good recall systems for women to have regular Pap Smears, Queensland has the 2 nd lowest participation rate of all States and Territories in 2006/7. One of the issues with the recall system in General Practice is that it depends on the woman returning for a Pap smear to remain in the system. The women who don t return may fall through the gaps and not receive follow up letters. Practices in Townsville have now started searching their whole population of women between years to follow up when they received their last Pap smear and then recalling the ones who have not. The Pap smear register also tracks these women but this still doesn t keep practice data up to date. This tracking and checking of data obviously has many barriers such as: Women may go to other surgeries such as Family Planning and the practice may not receive the results from the other organisation. Practice demographic information may not be up to date It is difficult to create a clean register of women years who have not had a hysterectomy. Practice incentive payments for Pap smear rates will increase to 65% from 50% on the 1 July By having accurate records of the practice pap smears rates you can monitor if your PIP payments are correct. Also there are SIP payments for women who haven t had a pap smear for over 4 years. The item numbers for this are 2501, 2504, and These are time based consultation numbers which trigger a SIP payment at medicare. The practice must register to be part of this program with medicare. More information is at: There are Data Extraction Tools available to General Practice to assist in this work. TMML can supply the Canning Data Extractor Tool for free. The tool gives the practice a register of women with no hysterectomy in sections of: Pap smear in the last 2 years Pap smear in the last 4 years No Pap smear for more than 4 years. (This is a good place to start checking) This information is picked up from the Pap smear area in Practice Software systems and the Pap smear result must be entered into this area by practitioners when they are checking results. A few software systems have made this easier by being able to access this area when checking results. Cervical cancer death rates have decreased by one-third during the past decade mostly as a result of the organised screening program, resulting in 23 fewer deaths per year in 2007 than there were in (The health of Queenslanders 2010) Compiled by Townsville Mackay Medicare Local January

64 Recording Data in my Practice Management Software Where should I put my data in my practice management software? Data should be entered in the appropriate places to be counted by the data extraction tool: Blood Pressure Medications HbA1c Total Cholesterol Recording Data in my Practice Management Software Enter in BP field (no free texting) Prescriptions Diabetes Record (HL7 pathology download format will assist with this) Diabetes Record (HL7 pathology download format will assist with this) Ensure doctors are familiar with recording within other areas of software: Blood pressure Weight Diabetes Record If your register is missing blood pressure values, there are 2 likely situations: The GP has not been recording the blood pressures correctly in your software i.e. they are entering BP into progress notes instead of the BP icon. A BP cannot be extracted unless it is entered into the BP field The patient may not have had a BP recorded in the last 12 months and this would therefore need to be reviewed in line with the Annual cycle of Care requirements for diabetes patients. Several actions can be taken to target/improve this area: Discuss with all GP s and Nurses the importance of entering blood pressures into correct field. Consider conducting a random audit of patients seen over a weekly period to ensure all BP s are being recorded correctly. Advise GP s of intention, to arouse some competition and subsequently gain compliance Enter a reminder into clinical software for GP to record BP in the appropriate area Other action to take to validate a register 1. Pathology test lists and downloading There may still be a gap in your register, of patients who have not been correctly coded and who may not be using diabetic drugs. This will identify the patients with diabetes who are diet controlled and have no coded diagnosis. It is recommended you contact your pathology company and ask them to send you a list of the last HbA1cs requested by your GPs over the last year. Once you have this list, you can cross check the names provided by the pathology company with the names identified by the extraction tool/register. Identify those not on the extraction tool/register list but on the pathology list and check the individual s medical record to determine whether the patient has diabetes. Add you re agreed upon coding e.g. Diabetes Mellitus Type 1 or Diabetes Mellitus Type 2 as appropriate, to the past history of the patient record. 2. Utilising Action Lists Uses for action list: Flagging patients annual cycle of care progress GPMP/ TCA eligibility, reviews due Flag to check aspirin or statin status Reminder for GP s to continue to code Compiled by Townsville Mackay Medicare Local January

65 Identifying patients who do not appear to be on aspirin & record Identify patients from your register who do not appear to be taking aspirin e.g. see latest extraction tool CHD Data for patients not recorded as being on aspirin Add an action or comment or enter into warnings in patient s file in clinical software for GP to check for compliance Alternatively, the RN or PM can review each identified patient s file and where no evidence of aspirin or warfarin, plavix etc, enter reminder for GP to check status and record The Chronic Condition Management support officer at the Townsville - Mackay Medicare Local can assist with correct coding of information and creating, validation and maintaining chronic condition registers. RECALLS Recall and review Effective recall and review has three key benefits. It will: Support quality patient care in chronic condition management Achieve the best financial outcome for the practice Meet the requirements of clinical guidelines and annual cycles of care There is no right or wrong way to set-up a recall and review system. Each practice will need to determine the system that is right for them. A computerized system is ideal, but recall and review can work equally well in paper diaries or exercise books. Testimonials In one practice the Clinic nurse sets a follow up or review appointment with the patient before they leave the clinic. The appointment gets entered into our GP clinical software so it is not lost, and Reception staff telephone the patient a week before their next appointment, to remind them and confirm their attendance. If the patient cannot attend a scheduled appointment, we reschedule the appointment while we have them on the telephone. No patient leaves without an appointment being made! The only real recall and review system we had in our practice was for Pap Smears. So we just mirrored that system for the Diabetes Clinic. It works well, as long as the nurse determines when the next appointment is required before the patient leaves, and Reception rebooks cancelled appointments. For both effective care and financial reasons Chronic Condition Management needs a robust recall and review system. As many practices do have effective recall and review systems, it is important to ensure the existing system is redeveloped to support Chronic Condition Management or where systems do not exist they are developed. The GP Management Plan and Team Care Arrangements have regular reviews built in (and specific timelines for completion), and an effective system will enable the practice to book patients in for these review appointments and send reminder letters when appointments draw near. Compiled by Townsville Mackay Medicare Local January

66 Setting up a Recall or Reminder system 1 Agree the purpose of the system 2 Map the workflow of the system 3 Appoint a staff member to be accountable for operating the system 4 Decide on the method and resources required for the system 5 Determine timing and schedule of activities 6 Agree on benchmarks for performance Consider if the system is a recall or reminder and what patients are to be targeted Work out the sequential steps of your system Who is responsible for generating the list of patients due for recall / reminder? Who contacts patient? All doctors / clinical staff should know how to enter recalls into the system. Administration / nursing staff should know how to generate recall / reminder lists and letters as appropriate to their role Methods could include: Post cards, Letters, Phone calls, s, Birthday cards, Mail outs, Opportunistic, SMS Letter templates can be set up in the practice clinical software. Use words and terms that are understandable for the patient How often will the recall / reminder be prompted? How often will they be checked against appointments made, results received etc? Staff should be able to dedicate set time on a regular basis to action and review recalls and reminders. The system should be reviewed for success at set intervals. How many appointments are being generated through reminders? Compiled by Townsville Mackay Medicare Local January

67 What constitutes a good system? Reminder and recall system have two elements: A. Recall or Remind the system to recall the patient for an abnormal test result or to remind the patient to attend the practice B. Tracking the system to track that the patient has attended the appointment or (for tests and referrals) to track when the results come in and that patient has been notified. The whole general practice team has a role in making sure recall/reminder systems are working effectively. Clinical GP makes the decision to recall the patient Administrative practice staff track and generate recall All staff members should understand their role (who generates list, who contacts patient, who notifies GP when initial attempts not successful). Staff needs to have dedicated time to this function. Clinical information systems Make sure the patient database is accurate and maintained (data cleansing). Make sure the right people know how to enter the recall/reminder. Understand the limitations of your clinical information system how reliable is it? What is the fall back system? Use Templates make sure letters are easy to understand for patients Are there safeguards in the system to ensure people don t get lost - flexibility to deal with a variety of circumstances Timeliness How often will reminders/recalls be sent? What is the appropriate timeframe between contacts? How often will they be checked against appointments made? Effective administration Make sure the recall/reminder is direct and detailed Make sure your patient databases are accurate (patient contact details, active patients) Ability to analyze the system How do you know if your system is effective? How effective / consistent is record keeping (in patient s health record)? Find out why patients are not responding (changed addresses, no longer attend your practice, personal circumstance)? Recall systems should make sure all attempts to contact a patient are documented in the patient s record. Following up the patient should involve Telephoning at different times of day and on different days (3 phone calls) Letters Registered mail is advised if having difficulty contacting patient If patient does not attend, doctor should be notified and advice sought from Medical Defense Organisation The recall is not complete until the specific matter is discussed with the patient by the doctor. Decide on how many contacts are made for preventive reminders (e.g. immunizations, pap smears due) and include in a practice policy. Multiple reminders are more effective. Compiled by Townsville Mackay Medicare Local January

68 TEMPLATES Templates Effective operation of chronic condition management can also be supported by a set of templates, within each system, in particular templates for: Communicating with patients such as letters for welcoming them to the clinic, or reminding patients that a review appointment is due Communicating with health professionals and specialists such as referrals for Allied Health appointments or engagement in TCAs GP Management Plans and Team Care Arrangements Other health checks Team Care Arrangements ereferral Management Tool The Team Care Arrangements Management System allows GPs to log-on and work through a template wizard to produce and send a TCA referral to multiple recipients on the system. This referral is also saved back to the Practice Management Software. Once the referral is received by the Allied Health Provider, he/she can send consent to be part of the TCA back to the GP, record visits used for patients and send feedback letters back to the referring GP. This is all recorded and kept on the system so all providers involved can see at a glance where the particular TCA status is up to. This is what the Management Console for the system looks like: The system is available to GPs through TMMLs Managed Health Network Allied Health Providers are able to access the system via a remote access account. Compiled by Townsville Mackay Medicare Local January