Chronic disease management in moira shire

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Chronic disease management in moira shire

  1. 1. Chronic Disease Management in Moira Shire Gillian Smith
  2. 2. Early Intervention in Chronic Disease <ul><li>EIiCD Moira Shire funding for 3 years commenced in 2009 </li></ul><ul><li>Collaborative between the 4 Health Services and Moira Healthcare Alliance </li></ul><ul><li>Aim to imbed Self Management practice into the organisations to better respond to clients with Chronic Disease </li></ul>
  3. 3. EIiCD Objectives <ul><li>1: Effective and active engagement of GPs in EIiCD Moira Shire </li></ul><ul><li>2: Develop a consistent intake process </li></ul><ul><li>3: Minimum Data Collection </li></ul><ul><li>4: Staff Professional Development </li></ul>
  4. 4. Effective and active engagement of GPs in EIiCD Moira Shire <ul><li>The GP is pivotal in patient management and primary contact for all things medical. </li></ul><ul><li>Logistical issues such as two divisions of GP requiring to be engaged due to differing boundaries compound process. </li></ul>
  5. 5. Effective and active engagement of GPs in EIiCD Moira Shire <ul><li>Differences in business practices of GP clinics –> all time poor and is general reason cited when attempting to engage them </li></ul><ul><li>Inconsistencies feedback processes concerning GP referrals across and within organisations which impact on relationships </li></ul>
  6. 6. Develop a consistent intake process <ul><li>To endeavour to have all 5 services undertaking some form of aligned intake process regardless of resources </li></ul><ul><li>Lack of minimum standards & continuity across the shire. Development of guidelines & infrastructure are pivotal in delivery of structured client pathways </li></ul>
  7. 7. Minimum Data Collection <ul><li>Investigate and analyse current practice across all CHC and GP practices via investigation of types of IT systems </li></ul><ul><li>Working with division of GPs to utilise their data retrieval systems where possible in GP practices (PENN Tool) </li></ul>
  8. 8. Minimum Data Collection <ul><li>Investigate what GVH IT can do with regard to building on BETTI </li></ul><ul><li>Comparison of data between health services difficult due to inconsistency of data collection reporting methods </li></ul>
  9. 9. Staff Professional Development <ul><li>Investigate training relevant to EIiCD with an even spread across Moira to maximise scarce resources. </li></ul><ul><li>Identify which staff, with current resources, are most appropriate for CCSM training </li></ul>
  10. 10. Staff Professional Development <ul><li>To ensure staff are not threatened by potential change and achieve this by top down approach ensuring senior management support for clinicians to adjust to change in structure and culture </li></ul><ul><li>CDSM programs such as Health Coaching, Better Health Self Management, Motivational Interviewing, Flinders Model identified as possibilities </li></ul>
  11. 11. Consumer Compliance <ul><li>Lack of client awareness of seriousness of un or poorly managed Chronic Disease which frustrates clinical delivery if clinician feels ill equipped in self help area </li></ul><ul><li>Drop out rates within existing chronic disease programs which questions their success and/or impact </li></ul><ul><li>All of the above are impacted upon by limited staff awareness of effective models of engagement </li></ul>
  12. 12. Outcomes………. so far <ul><li>Staff trained in Health Coaching, PDSA and ‘My Health, My Life’ (Motivational Interviewing may occur in the future) </li></ul><ul><li>Development of resources to support practice e.g. Intake Questions </li></ul><ul><li>Use of Care Coordination Plan as Self Management Plan </li></ul><ul><li>GP Feedback – trialing use of standardised letters (using guidelines) </li></ul><ul><li>Trialing Health Planner (Cobram only) </li></ul>
  13. 13. Barriers <ul><li>NO practical application for staff utilising training; staff reporting hours of service but some inconsistencies. </li></ul><ul><li>All staff at same level – no level of expertise – ‘Champion’ needed to drive practice within each organisation </li></ul><ul><li>Staff time – ICDM AND EIiCD. Both require commitment of time. </li></ul><ul><li>Data reporting systems remain different </li></ul>

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