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Chronic Disease Management

Chronic Disease Management . Beyond CDM Payments Dr Bruce Davies. Scope. What common diseases? Should they be formally managed? Frequency Importance Follow up affects outcome Know what to do Where is follow-up most appropriate?. Brainstorm.

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Chronic Disease Management

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  1. Chronic Disease Management Beyond CDM Payments Dr Bruce Davies

  2. Scope • What common diseases? • Should they be formally managed? • Frequency • Importance • Follow up affects outcome • Know what to do • Where is follow-up most appropriate?

  3. Brainstorm • What conditions are important under these criteria?

  4. Perhaps • Diabetes • Asthma • COPD • Hypertension • ? Epilepsy • High risk drug users ie DMARDs etc • Contraception

  5. CDM Payments • Asthma • Diabetes • Small fee per GP per year • Criteria to claim • Requirement for audit

  6. Ways and Means • Opportunistic • Dedicated clinics • Nurse led clinics • Specific appointments • Disease registers • Protocols • Guidelines

  7. Better Care or Just PC • Sometimes hard to tell! • Evidence for effectiveness? • Need for audit • More work • More treatment • More iatrogenic problems?

  8. Polyclinic Model of Care • The list of things can grow and grow. • Advantages. • Disadvantages. • Professional satisfaction. • Quality. • Fragmentation. • Fall between two stools.

  9. Generalist Model • Copes with everything. • Advantages. • Disadvantages. • Professional satisfaction. • Holistic. • Failure to care systematically.

  10. Registers • Creation. • Maintenance. • Accuracy. • Usage. • Whose responsible? • Manual viz. Computer.

  11. Protocols • Authority. • Ownership. • Access. • Who follows. • Benefits. • Disadvantages. • GOBSAT viz. EBM.

  12. Records • Whose responsible? • Paper or computer? • Accuracy. • Meaning. • Why poor?

  13. Audit • PC or use? • Who does? • More work for what value? • Do people change as a result?

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