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ABHI Primary Care Integration Project Local Clinical & Service Delivery Pathways Jon Goodman. Where have we been?. Aim: Integrate, coordinate chronic disease care Established chronic disease committee Mapped best practice clinical pathways Business process mapping x 5 diseases
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ABHI Primary Care Integration ProjectLocal Clinical & Service Delivery PathwaysJon Goodman
Where have we been? • Aim: Integrate, coordinate chronic disease care • Established chronic disease committee • Mapped best practice clinical pathways • Business process mapping x 5 diseases • Compared current practice to best practice • 5 practices & 90 patients; file audit & interview • Variable practice, better for some patients & conditions
What did we decide to do? • Recommendations • Develop pathways that seamlessly integrate systems to support good care • Systemise screening activity applied to some diabetes patients & spread to other diseases NEXT • Identified local needs, interests • Services, communication, systems • Developed & tested pathways • Advice from Pathways Reference Groups & CD Committee • 26 representatives from primary health care • Established Prevention Collaborative
What have we found? Pathways …. • Serve as clinical decision support tool • Guide on delivering best practice • Access to relevant evidence, tools, resources • Help improve teamwork, coordination of care • Increase patient access to services • Comprehensive local services information • Common assessment, referral, feedback tools • Help integrate best practice into business systems • Link with Medicare • Provision of electronic communication
Let’s looks at pathways • http://www.gpgc.com.au/pathways/Default.aspx • Newly diagnosed renal disease
Where to from here? • Conduct 8 month activity with larger group • Up to 40 practices & their 5 key allied health or community service providers • Trial with 20 patients from each practice • Develop, implement shared business protocols • Free installation of Medical Objects • Simple patient registry to track patients • Evaluation for quality improvement
Still working on … • Marketing pathways to • General practice • Allied health • Community services • Developing business protocols • Draft allied health referral template • Engaging with local community services • Prevention Collaborative