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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

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
slide5

5 General Practices

  • 155 referrals
  • 138 patients commenced program
  • 135 completed to date(97.8% retention rate )
slide6

100% patients interviewed stated that they have:

    • Made changes to their behaviour
    • Attitudes have changed
    • They feel more in control of their lives, health and wellbeing.
slide7

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

slide8

Critical

Success

Factors

  • Partnerships
  • Systems
  • Leadership & Relationships
  • Access
slide9

Critical

Success

Factor 1

Partnerships

  • Culture
  • Systems
  • Communication
  • Communication
  • Communication
  • Communication
  • Communication
  • Communication
  • Communication
  • Communication
slide10

What

Partnerships?

  • General Practices + GPGC
  • General Practices + Spiritus
  • GPs and front office staff
  • Spiritus + patients
  • Spiritus and other service agencies
  • Patients + GPs
slide11

Information

  • 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?
slide12

Critical

Success

Factor 2

Systems

  • Referral systems
  • Feedback systems
  • Monthly scheduling
slide13

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.
slide14

Critical

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
slide15

Critical

Success

Factor 4

Access

  • Transport
  • Accompanying person
slide16

What is the perspective of GPs?

Dr Sue GardenerRunaway Bay Doctors Surgery

slide17

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
slide18

By giving the front desk ownership of the issue and then follow through by the GP, we found the system worked remarkably well.

  • Significant burden of GP is CD and this helped the practice in supporting, educating, improving care in these pt groups.
slide19

Conclusion

  • √The Partnership approach
  • √ Supportive and professional course delivery model
  • √ GPs and General Practices – new ways of working
  • √ Patients – embracing health & lifestyle change & taking responsibility
slide20

?

Questions

slide21

Thank you

Sara Drew

[email protected]

Ph: 5507 7777

Mbl: 0448 154 981

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