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CCM Programme

CCM Programme. The problem. Increasing acute medical admission rate Rapidly growing rate of diabetes in population Concern re primary care management and patient self management. Acute Medical Demand - MMH. We could wait for help or………. How we did it – CCM programme.

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CCM Programme

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  1. CCM Programme

  2. The problem • Increasing acute medical admission rate • Rapidly growing rate of diabetes in population • Concern re primary care management and patient self management

  3. Acute Medical Demand - MMH

  4. We could wait for help or……….

  5. How we did it – CCM programme Based on Wagner’s Chronic Care model • High need patients • Co-morbidity focus (Diabetes, COPD, CHF, CVD) • 4 free proactive practice visits per annum • 6 hours nursing/CHW time per annum • Structured notes • Embedded within practice computer software • Empowered and proactive primary care • Secondary outreach/training • Electronic clinical decision support • Regular reporting on progress • Empowered Patients • Patient held care (wellness) plans

  6. Chronic Care Management Prog. Secondary Tertiary CCM Intensity of Intervention Primary Care Self Care Public Health Severity of Condition

  7. How we did it • Project Started: 2001 • Staffing: • DHB staff: 1 FTE clinical director, 1 project manager, 1 IT support. • Hospital – 2+ chronic care nurses. Help from 4 specialists • PHOs – 0.5-2.0 clinical programme managers • Funding: $1.6m this year • Duration: as long as it takes! • Now 5001 patients enrolled (4585 in diabetes) The CCM motivational team

  8. Evaluation – Key Findings

  9. Targeting High Needs In addition – Maori/PI were just as likely or more likely to be prescribed key medications compared with non-Maori/PI

  10. Cholesterol/Lipid Levels - diabetes • Statin prescribing increased from 49% at enrolment to 77% currently • Mean LDL cholesterol levels dropped from 3.0 at enrolment to 2.6 currently

  11. Smoking

  12. Blood Sugar Levels (HbA1c)

  13. In-patient Utilisation

  14. Recommendations • What we recommend to others • Team approach – within practices and between primary and secondary • IT support so processes and outcomes are easily measured and tracked over time • Don’t’ expect saved bed days for diabetes within the short term • What we will do differently • Greater emphasis on supporting patients self management • More help to practices to improve their systems • Greater use of reports for quality improvement • Trial financial incentives for outcomes • Progress to primary prevention and screening Emphasis on the team approach

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