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Jacki Eckert
Program Manager
Practice Support - CDM, Accreditation, IT/IM & Practice Nurses
Ph: 02 6049 1906
Email: jeckert@bordergp.org.au
What is Chronic Disease Management in general practice?
The well documented current and future increase in chronic disease in Australia means that health providers in the primary care field will be at the forefront of managing increasingly complex clients in the community. General practice has a major ongoing and changing role to play in management and treatment, care coordination, education and advocacy for these clients.
Health education, health promotion, self management education, allied health collaboration and providing or enabling access to support programs aimed at promoting good health, reducing the risk of illness, symptom recognition and management and prevention of exacerbations are beconming a major part of general practice business.
Having a focus on working in an integrated (and cross border) system means that general practice, state and federally funded services and agencies, hospitals, ambulatory care and other care providers in the community have clear understanding of health funding, role delineation, paths of engagement and referral. This will then lead to timely and relevant communication, referral and transition and an easier and more effective journey for patients as they navigate the health system. All health providers need to be able to continually improve use of both workforce and technology.
In the AWRGPN area we look to assist general practice and other health providers to:
- engage with the work of the Primary Care Partnerships and other key stakeholders, to improve service co-ordination and integrated chronic disease prevention and management
- make better use of existing primary and community care services including commonwealth, state and non-government organisation funded services with a focus on patients with chronic disease and complex conditions
- utilise tools/strategies that will assist in better managing patients with chronic disease
A key objective is that general practices have a sustainable system that supports more integrated primary and community care services.
How can the Network help you?
The Network can provide information and resources on:
- e-referral via Connectingcare or other e-health providers
- chronic disease management in general practice
- flow charts for mental health and diabetes pathways using MBS
- local services contributing to chronic disease management
- PEN Clinical Audit Tool and cleaning/use of practice clinical data
- templates for communicating clinical information to general practice
- Lifestyle modification programs
There are also resources both general and clinical, able to be accessed under the tabs at the top of the page
Designed withwebsite hosting of America, good services
Documents
To Save a File in Best Practice
To Save a File in MD
Six Clicks for Electronic Referal Flowchart 2008
GPMP TCA - Patient Information.pdf
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Wodonga Healthy Communities Plan 20019-2013
Integrated Chronic Disease Management (link)
General Practice Victoria - MBS Funded Allied Health Services Information
Argus and MO Interoperability Media Release August 2009
Albury/Wodonga Health - Wodonga Campus Community Rehab Centre Services
Connectingcare Overview MBS Workshop
Dementia Clinical Pathway Flow Chart
General Practice Engagement in Integrated Chronic Disease Management
HealthConnectSA - Change Management in General Practice
Whitehorse Division - Principles for Written Communication to GPs
Fact Sheet for Allied Health - Enhanced Primary Care
Fact Sheet for General Practice - Enhanced Primary Care
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These templates were developed in collaboration with Albury Wodonga Health - Wodonga Campus Community Rehabilitation Centre to improve communicaiton between allied health and general practice. They can be downloaded and changed to include your clinic details and to match clinical software, but we would appreciate acknowledgement of the developers on the template.
Initial Assessment Template
Change in Condition Treatment Letter Template
Discharge Template
Other templates
General Practice Victoria - Letters from GPV to Allied Health re: Patient Ineligibility for TCA
General Practice Victoria - Statewide Referral Form
Care Planning and Health Assessment templates (link)
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Australian Association for Exercise and Sports Science (AAESS)
For information on referring to an Accredited Exercise Physiologist and Referral Forms in Medical Director and Best Practice Formats.
Albury Community Health
Albury/Wodonga Health - Wodonga Campus Community Rehabilitation Centre
City of Wodonga - Home and Community Care Services (HACC)
Gateway Community Health (link)
Greater Southern Area Health Service (link)
Medicare Online (link)
Upper Hume Primary Care Partnership (link)
E-referral and service directory - Connectingcare
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Claiming rules for SIP payments
Chronic Disease Management Item Number Flow Chart 2010
Chronic Disease and Indicators for Palliative Care
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Allied Health Professionals Australia CDM manual (link)
Chronic Disease Management Resource Manual
Diabetes Fax Back Sheet
MBS Items Guide for Palliative Patients and Carers
Medicare Chronic Disease Items: 721-731
RACGP Guidelines
Green Book - Putting Prevention into Action
Red Book - Preventative Activities in General Practice
SNAP - Population Guide to Behavioural Risk Factors in General Practice
RACGP Guidelines for Chronic Illness in General Practice
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Clinical Software Templates and Other Resources
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Australian Disease Management Association
Arthritis
Cardiovascular Disease
Chronic Disease Self Management
QUIT
Nutrition Australia
Chronic Condition Self Management Guidelines
Diabetes - Prevention and Support
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