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CCM Programme. The problem. Increasing acute medical admission rate Rapidly growing rate of diabetes in population Concern re primary care management and patient self management. Acute Medical Demand - MMH. We could wait for help or………. How we did it – CCM programme.

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Presentation Transcript
the problem
The problem
  • Increasing acute medical admission rate
  • Rapidly growing rate of diabetes in population
  • Concern re primary care management and patient self management
how we did it ccm programme
How we did it – CCM programme

Based on Wagner’s Chronic Care model

  • High need patients
  • Co-morbidity focus (Diabetes, COPD, CHF, CVD)
  • 4 free proactive practice visits per annum
  • 6 hours nursing/CHW time per annum
  • Structured notes
    • Embedded within practice computer software
  • Empowered and proactive primary care
    • Secondary outreach/training
    • Electronic clinical decision support
    • Regular reporting on progress
  • Empowered Patients
    • Patient held care (wellness) plans
chronic care management prog
Chronic Care Management Prog.

Secondary Tertiary

CCM

Intensity of Intervention

Primary Care

Self Care

Public Health

Severity of Condition

how we did it
How we did it
  • Project Started: 2001
  • Staffing:
    • DHB staff: 1 FTE clinical director, 1 project manager, 1 IT support.
    • Hospital – 2+ chronic care nurses. Help from 4 specialists
    • PHOs – 0.5-2.0 clinical programme managers
  • Funding: $1.6m this year
  • Duration: as long as it takes!
  • Now 5001 patients enrolled (4585 in diabetes)

The CCM motivational team

targeting high needs
Targeting High Needs

In addition – Maori/PI were just as likely or more likely to be prescribed key medications compared with non-Maori/PI

cholesterol lipid levels diabetes
Cholesterol/Lipid Levels - diabetes
  • Statin prescribing increased from 49% at enrolment to 77% currently
  • Mean LDL cholesterol levels dropped from 3.0 at enrolment to 2.6 currently
recommendations
Recommendations
  • What we recommend to others
    • Team approach – within practices and between primary and secondary
    • IT support so processes and outcomes are easily measured and tracked over time
    • Don’t’ expect saved bed days for diabetes within the short term
  • What we will do differently
    • Greater emphasis on supporting patients self management
    • More help to practices to improve their systems
    • Greater use of reports for quality improvement
    • Trial financial incentives for outcomes
    • Progress to primary prevention and screening

Emphasis on the team approach