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Partnering in Chronic Disease Self Management

Sara Drew RN Jo Setter

Background

• 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

Why partnering in self management

• 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

Chronic Conditions Self Management

• 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

• 5 General Practices

• 155 referrals

• 138 patients commenced program

• 135 completed to date(97.8% retention rate )

• 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.

Patient with chronic condition

identified by General Practice as candidate for General Practice

Management Plan

GP Referralto Spiritus

CCSM program

GP Referral to other relevant service

SpiritusSpiritus6 week

facilitated programFeedback to GPFeedback to GP• Patient

Action Plan• Letter to GP

outlining commitments and

progress

CCSM Participants / CCSM Participants / SpiritusSpiritus

3 month follow upGP / Patient6 – 8 month follow up

GP / Patient3 – 5 month

follow up

Spiritus Notification

to GP re enrolment

Patient visits GP

• PartnershipsPartnerships

• SystemsSystems

• Leadership & RelationshipsLeadership & Relationships

• AccessAccess

Critical Critical Success Success FactorsFactors

• Culture

• Systems

• Communication• Communication• Communication• Communication• Communication• Communication• Communication• Communication

Critical Critical Success Success Factor 1Factor 1

PartnershipsPartnerships

• General Practices + GPGC

• General Practices + Spiritus

• GPs and front office staff

• Spiritus + patients

• Spiritus and other service agencies

• Patients + GPs

WhatWhatPartnerships?Partnerships?

• GPs and practice staff need to GPs and practice staff need to understand the CCSM program understand the CCSM program coursecourse

1. What are patients going to learn?

2. How will patients learn it?

3. What is the “language” GPs need to know and understand?

InformationInformation

• Referral systems

• Feedback systems

• Monthly scheduling

Critical Critical Success Success Factor 2Factor 2

SystemsSystems

• 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.

• GP follow-up with patient

• Spiritus support for participants

• Trust in the facilitators

• Relationships in the groups

• Action Learning over 6 week period

Critical Critical Success Success Factor 3Factor 3

LeadershipLeadership&&

RelationshipsRelationships

• TransportTransport

• Accompanying personAccompanying person

Critical Critical Success Success Factor 4Factor 4

AccessAccess

What is the perspective of GPs?What is the perspective of GPs?

Dr Sue GardenerDr Sue GardenerRunaway Bay Doctors Surgery

• 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

• 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.

• √The Partnership approach

• √ Supportive and professional course delivery model

• √ GPs and General Practices – new ways of working

• √ Patients – embracing health & lifestyle change & taking responsibility

ConclusionConclusion

??QuestionsQuestions

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Thank you

Sara Drew

sarad@gpgc.com.au

Ph: 5507 7777

Mbl: 0448 154 981

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