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Partnering in Chronic Disease Self Management Sara Drew RN Jo Setter . CCSM was funded by the Gold Coast Primary Care Partnership Council (PCPC) PCPC recognises that better health and well being can be achieved through working together

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Presentation Transcript

Background

CCSM was funded by the Gold Coast Primary Care Partnership Council (PCPC)

PCPC recognises that better health and well being can be achieved through working together

PCPC comprises gov’t, NGO, local council, communities, general practice

Background


Why partnering in self management

Benefits of self mgnt well known Council (PCPC)

Address known problems:

Physical access for patients is critical

Courses run in isolation aren’t effective

Outcomes integrated into a holistic health plan

GPs reluctance to refer

Stop/ start nature of courses

Why partnering in self management


Chronic conditions self management

Trial partnership between GPGC, Spiritus, general practice and Kalwun

CCSM to be a part of the patient's health care plan

Efficient referral and communication systems

Feedback to GPs informing further care planning

GPGC utilised the collaborative methodology to learn throughout the trial

Partnerships work

Chronic Conditions Self Management


  • 5 General Practices and Kalwun

  • 155 referrals

  • 138 patients commenced program

  • 135 completed to date(97.8% retention rate )



Patient with chronic condition identified by General Practice as candidate for General Practice Management Plan

GP Referral

to Spiritus CCSM program

Spiritus Notification

to GP re enrolment

GP Referral

to other

relevant service

Spiritus

6 week facilitated program

  • Feedback to GP

  • Patient

  • Action Plan

  • Letter to GP outlining commitments and progress

GP / Patient

3 – 5 month follow up

Patient visits GP

CCSM Participants / Spiritus

3 month follow up

GP / Patient

6 – 8 month follow up


Critical Practice as candidate for General Practice Management Plan

Success

Factors

  • Partnerships

  • Systems

  • Leadership & Relationships

  • Access


Critical Practice as candidate for General Practice Management Plan

Success

Factor 1

Partnerships

  • Culture

  • Systems

  • Communication

  • Communication

  • Communication

  • Communication

  • Communication

  • Communication

  • Communication

  • Communication


What Practice as candidate for General Practice Management Plan

Partnerships?

  • General Practices + GPGC

  • General Practices + Spiritus

  • GPs and front office staff

  • Spiritus + patients

  • Spiritus and other service agencies

  • Patients + GPs


Information Practice as candidate for General Practice Management Plan

  • GPs and practice staff need to understand the CCSM program course

    • What are patients going to learn?

    • How will patients learn it?

    • What is the “language” GPs need to know and understand?


Critical Practice as candidate for General Practice Management Plan

Success

Factor 2

Systems

  • Referral systems

  • Feedback systems

  • Monthly scheduling


  • 80% of participants consulted stated that their doctor’s recommendation was a key factor in participating.

  • The partnership approach helps to “legitimise” the program.

  • Post course follow-up with the GP where action planning, goals and progress is discussed is essential for integrated health management.


Critical recommendation was a key factor in participating.

Success

Factor 3

Leadership

&

Relationships

  • GP follow-up with patient

  • Spiritus support for participants

  • Trust in the facilitators

  • Relationships in the groups

  • Action Learning over 6 week period


Critical recommendation was a key factor in participating.

Success

Factor 4

Access

  • Transport

  • Accompanying person


What is the perspective of GPs? recommendation was a key factor in participating.

Dr Sue GardenerRunaway Bay Doctors Surgery


  • Our front office staff play a key role in recognising the needs of our patients.

  • They know our patients and are often better at identifying suitable candidates for courses.

  • GPs can be too busy or time poor to pick up on the verbal or non-verbal clues from patients

  • Maximises SM moving away from the medical model



Conclusion follow through by the GP, we found the system worked remarkably well.

  • √The Partnership approach

  • √ Supportive and professional course delivery model

  • √ GPs and General Practices – new ways of working

  • √ Patients – embracing health & lifestyle change & taking responsibility


? follow through by the GP, we found the system worked remarkably well.

Questions


Thank you follow through by the GP, we found the system worked remarkably well.

Sara Drew

[email protected]

Ph: 5507 7777

Mbl: 0448 154 981


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