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Partnering in Chronic Disease Self Management Sara Drew RN Jo Setter

Partnering in Chronic Disease Self Management Sara Drew RN Jo Setter . CCSM was funded by the Gold Coast Primary Care Partnership Council (PCPC) PCPC recognises that better health and well being can be achieved through working together

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Partnering in Chronic Disease Self Management Sara Drew RN Jo Setter

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  1. Partnering in Chronic Disease Self ManagementSara DrewRN Jo Setter

  2. CCSM was funded by the Gold Coast Primary Care Partnership Council (PCPC) PCPC recognises that better health and well being can be achieved through working together PCPC comprises gov’t, NGO, local council, communities, general practice Background

  3. Benefits of self mgnt well known Address known problems: Physical access for patients is critical Courses run in isolation aren’t effective Outcomes integrated into a holistic health plan GPs reluctance to refer Stop/ start nature of courses Why partnering in self management

  4. Trial partnership between GPGC, Spiritus, general practice and Kalwun CCSM to be a part of the patient's health care plan Efficient referral and communication systems Feedback to GPs informing further care planning GPGC utilised the collaborative methodology to learn throughout the trial Partnerships work Chronic Conditions Self Management

  5. 5 General Practices • 155 referrals • 138 patients commenced program • 135 completed to date(97.8% retention rate )

  6. 100% patients interviewed stated that they have: • Made changes to their behaviour • Attitudes have changed • They feel more in control of their lives, health and wellbeing.

  7. Patient with chronic condition identified by General Practice as candidate for General Practice Management Plan GP Referral to Spiritus CCSM program Spiritus Notification to GP re enrolment GP Referral to other relevant service Spiritus 6 week facilitated program • Feedback to GP • Patient • Action Plan • Letter to GP outlining commitments and progress GP / Patient 3 – 5 month follow up Patient visits GP CCSM Participants / Spiritus 3 month follow up GP / Patient 6 – 8 month follow up

  8. Critical Success Factors • Partnerships • Systems • Leadership & Relationships • Access

  9. Critical Success Factor 1 Partnerships • Culture • Systems • Communication • Communication • Communication • Communication • Communication • Communication • Communication • Communication

  10. What Partnerships? • General Practices + GPGC • General Practices + Spiritus • GPs and front office staff • Spiritus + patients • Spiritus and other service agencies • Patients + GPs

  11. Information • GPs and practice staff need to understand the CCSM program course • What are patients going to learn? • How will patients learn it? • What is the “language” GPs need to know and understand?

  12. Critical Success Factor 2 Systems • Referral systems • Feedback systems • Monthly scheduling

  13. 80% of participants consulted stated that their doctor’s recommendation was a key factor in participating. • The partnership approach helps to “legitimise” the program. • Post course follow-up with the GP where action planning, goals and progress is discussed is essential for integrated health management.

  14. Critical Success Factor 3 Leadership & Relationships • GP follow-up with patient • Spiritus support for participants • Trust in the facilitators • Relationships in the groups • Action Learning over 6 week period

  15. Critical Success Factor 4 Access • Transport • Accompanying person

  16. What is the perspective of GPs? Dr Sue GardenerRunaway Bay Doctors Surgery

  17. Our front office staff play a key role in recognising the needs of our patients. • They know our patients and are often better at identifying suitable candidates for courses. • GPs can be too busy or time poor to pick up on the verbal or non-verbal clues from patients • Maximises SM moving away from the medical model

  18. By giving the front desk ownership of the issue and then follow through by the GP, we found the system worked remarkably well. • Significant burden of GP is CD and this helped the practice in supporting, educating, improving care in these pt groups.

  19. Conclusion • √The Partnership approach • √ Supportive and professional course delivery model • √ GPs and General Practices – new ways of working • √ Patients – embracing health & lifestyle change & taking responsibility

  20. ? Questions

  21. Thank you Sara Drew sarad@gpgc.com.au Ph: 5507 7777 Mbl: 0448 154 981

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