A population health approach is recognized as the most effective way to address the morbidity and mortality impacts of chronic diseases. This approach is based on a disease continuum from prevention, through early identification, best practice management, rehabilitation, and palliative care.
From 1 July 2005 items in the Medicare Benefits Schedule make it easier for GPs to manage the health care of patients with chronic medical conditions, including patients who need multidisciplinary care. The Chronic Disease Management (CDM) items apply to treatment of people with asthma, cancer, arthritis, diabetes, heart disease, mental illness and other chronic medical conditions and build on earlier initiatives focusing on enhancing primary care and increasing access to allied health services.
Sustained improvements in health outcomes for people with chronic diseases such as diabetes have been associated with a multidisciplinary, systematic approach in general practice including intensive follow up, use of clinical management guidelines integrated with self-management support programs and more effective use of non-physician care providers. Systematic care includes having a disease register, regular recall and review, protected time, a practice nurse, clear written guidelines and a system for auditing standards of care.
To assist GP access General Practices to take a proactive approach to managing patients with chronic diseases the GP access provides:
- Telephone support and advice
- Practice based support and visits on request
- Workshops on Chronic Disease Management and related activities
- Provision and facilitation of appropriate information about IM/IT systems currently available, advantages and benefits of information management to clinical work and practice management. This includes support in the utilization of templates to improve efficiency and accuracy in documentation – templates we recommend can be downloaded from the Related Resources Section of this page
For more information contact Marilyn Taylor or Denise Lyons Ph: 4925 2259
