|
Powered withcheap hosting
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 becoming a major part of general practice business. It is also of paramount importance that education, resources and health promotion activites undertaken in general practice are culturally appropriate and take into account the health literacy level of clients and their families.
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:
- participate in local interprofessional education and networking opportunities
- 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:
- secure messaging
- electronic care planning
- chronic disease management in general practice incl. nurse coordinated clinics
- Medicare information and resources
- local services contributing to chronic disease management
- PEN Clinical Audit Tool and cleaning/use of practice clinical data to improve service and outcomes and to stop patients "falling through the gaps"
- templates for communicating clinical information to general practice
- Lifestyle modification programs for those identified at risk of Type 2 diabetes
- local education opportunities
- nurse coordinated care
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 |