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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

Chronic Disease Management

Beyond CDM Payments

Dr Bruce Davies

scope
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
Brainstorm
  • What conditions are important under these criteria?
perhaps
Perhaps
  • Diabetes
  • Asthma
  • COPD
  • Hypertension
  • ? Epilepsy
  • High risk drug users ie DMARDs etc
  • Contraception
cdm payments
CDM Payments
  • Asthma
  • Diabetes
  • Small fee per GP per year
  • Criteria to claim
  • Requirement for audit
ways and means
Ways and Means
  • Opportunistic
  • Dedicated clinics
  • Nurse led clinics
  • Specific appointments
  • Disease registers
  • Protocols
  • Guidelines
better care or just pc
Better Care or Just PC
  • Sometimes hard to tell!
  • Evidence for effectiveness?
  • Need for audit
  • More work
  • More treatment
    • More iatrogenic problems?
polyclinic model of care
Polyclinic Model of Care
  • The list of things can grow and grow.
  • Advantages.
  • Disadvantages.
  • Professional satisfaction.
  • Quality.
  • Fragmentation.
  • Fall between two stools.
generalist model
Generalist Model
  • Copes with everything.
  • Advantages.
  • Disadvantages.
  • Professional satisfaction.
  • Holistic.
  • Failure to care systematically.
registers
Registers
  • Creation.
  • Maintenance.
  • Accuracy.
  • Usage.
  • Whose responsible?
  • Manual viz. Computer.
protocols
Protocols
  • Authority.
  • Ownership.
  • Access.
  • Who follows.
  • Benefits.
  • Disadvantages.
  • GOBSAT viz. EBM.
records
Records
  • Whose responsible?
  • Paper or computer?
  • Accuracy.
  • Meaning.
  • Why poor?
audit
Audit
  • PC or use?
  • Who does?
  • More work for what value?
  • Do people change as a result?