Andrew Knight
The people at Mt Barker/Balhannah Medical Clinic in South Australia were part of the second wave of the Collaborative back in 2005. They remind us that “care redesign” is one of the pillars of effective chronic care. That is you can’t keep doing the same thing and expect different results!
What did they do? Like many of the successful practices in the collaborative they created a new creature –the chronic disease coordinator.
“We have made quite a few changes but I believe the most significant change was brought about by employing a Registered Nurse to co-ordinate chronic disease management.
The first plan we tried was to have the nurse identify our patients with high HBA1C levels and invite them to a diabetic clinic which involved the clinical nurse, diabetic educator and doctor with an appointment at a later date with the podiatrist if indicated.
Now rather than running a dedicated diabetes clinic our nurse manages the recall of our diabetic patients in order to complete cycles of care (and achieve PIP recognition). She is adept at checking appointment schedules to achieve these outcomes.
Our doctors are now much more opportunistic and will identify patients who present with “risk” factors. These patients have the necessary tests ordered and see our chronic care coordinator, with the doctors signing off after consultation and planning. She also performs home health reviews and identifies those who may benefit from home medication reviews. Other functions include following up our outstanding pathology results – making sure all patients have been notified of abnormalities and irregularities and ensuring they have appointments to discuss their results with their doctor. From these patients she will make appointments if indicated by doctor and accepted by patient, for chronic disease management.
In our Practice of six – seven doctors, the demands of clinical nursing were increasing rapidly. By using our Chronic Disease Management Nurse we were able to rethink how we addressed our patients’ needs, we had more time to look at being much more pro-active in seeking out patients who were at risk.”
By making chronic disease care an explicit, resourced, “job-descriptioned”, core part of their way of working general practices like Mt Barker/Balhannah Medical Clinic are leading the way.
Have you redesigned your practice to include a chronic disease coordinator role? Make a comment and share your good idea below.
16 Comments
I totally agree in the idea of a CCC – at the moment with us, it is a job shared between the clinic manager, practice nurse and enrolled nurse and some of the doctors! cheers Jenni
great idea but is this and extra nurse on top of the regular staff ( how many nurse FTEs do you have ?
1. Some info on the ‘financial modelling’ used to justify the cost of an extra nurse dedicated to CDCare would be important to me.
2. Also – what are the national average ratio for private GP “FTE prac nurse : FTE GP” or vice versa?? and what if any data is avaialable on the ‘ideal’ ratio for this?
I think these days a CCC is a must. Most of the work performed seems to be administrative and / or preparation for the doctor so I feel it is very hard to track the cost / benefits of this extra nurse. At present the way we monitor the benefits is by checking to see if the CDM items billed have been increasing since hiring our CCC. The most important thing to us in maximising the benefits of these plans for the patient and medical staff / practice, is to ensure everyone is on board with the program and working together as a team. When a member of the team doesnt complete their part, the plan may not get completed (nurse time wasted), the item doesnt get billed (nurse and GP time wasted) or both (everyones time wasted). We have developed ‘tracking sheets’ for each patient having a ‘plan’ to ensure the whole process from identifying the patient through to billing is completed. These tracking sheets allow any member of the team to check on a patients ‘Plan’ progress and to act as a reminder of the many steps involved in completing the ‘Plan’ cycle.
Dear Mary, your idea of a tracking sheet sounds great!! could you show the plan & demonstrate how it would be used ? Thanks Rose
Hi Mary
The way you are tracking you patients is a great idea. I too would like to see you plan and how it is used.
Hi Mary, I would like a copy of the tracking sheet to pass onto my collabs. This sounds like a great idea.
Great idea – we would also like an example of the tracking sheet you found the most workable
This sounds a great idea for nursing and administration staff to refer to and we too would like a copy of the tracking sheet. Thank you
I have been working in the role of CDC since Feb 2008 when the PN was employed to assist Drs with Health Assessments/Plans for ‘at risk pts’, elderly & chronic disease pts. It was realised that getting pts in for appts was an administrative role, therefore could be done by admin staff who are paid less than an RN.I work alongside the RN/Drs and basically organise all the recalls,book the RN’s appts a week ahead, recheck validity of timimg of the different appts to ensure recalls are not done too early,track staff/Drs have claimed correctly, search data base for potential new clients for gpmp, 75+ HA, 45-49+ HA +4 yo HA.I also submit + analyse monthly data then discuss the results with Drs/RN + other staff at meetings[some tool box].Perhaps all of us who work in this role could write up our duties we perform to assist others. What do you think??
Hi,
We love this idea. Does anyone have a Job Description that we could use as a basis for developing ours?
thanks, Trish
I have a rough Job Description typed up so I will update + improve it & forward onto all next week hopefully.
Thanks for everyone’s comments.
Mary’s tracking sheets have been uploaded to this page (click)
What a great idea the tracking sheet is. I would like to implement this at our Surgery. I noticed on December 9th Admin replied that they have a rough job description typed up. I would love a copy of that if at all possible please?
Raelene
I have finally updated my Chronic Disease Coordinator Job Description & have included at the bottom for all to use. Please remember that I am a receptionist with an enrolled nursing back ground. I would like to see anyone elses if u have one. linda
Chronic Disease Coordinator [Clerical Staff] Job Description
To assist Doctors, Practice Nurse and patients in the effective management of chronic
disease care.
Provide efficient service directly relating to patient recall and follow-up
appointments.
Liaison with Doctors and Practice Nurse on matters pertaining to chronic disease and those patients within the Practice & community to level of training.
Effectively use the computer programs necessary to obtain the data needed to
perform duties.
Monitor and ensure appropriate claiming of GPMP, TCA and SIP payments.
Duties & Responsibilities:
■Manage the Practice Nurse’s workload/appointments; keeping 1 week ahead of him/her
using the recall system and Doctors direction.
■Monitor the chronic heart disease, diabetes pts,75, 45-49 and 4 year old patients, Pap smear recalls, immunization catch-up program using Best Practice search function, recall system and Penn Cat Clinical Audit program.
■New 75 yo health assessments: phone these patients to offer and explain the assessment process and then arrange appointments for the Practice Nurse to visit them at home or see in the clinic. Monitor patients to ensure follow up appointments with the Doctor are
carried out.
Annual health checks on all 75 yo patients organise weekly.
■45-49 health assessments and 4 yo Healthy Kids Check : letters of invitation and
subsequent monitoring every 6 months.
■Extract data monthly: examine reports and evaluate clinical results for improvements or decline. In consultation with Doctors & Practice Nurse, recall patients for further
monitoring/tests.
■Immunisation catch-up program: letter sent explaining the program and invitation offered to eligible patients .
■Pap smear results,: notification of results and recommended repeat smear test letters.
Recalls added to patients file.
■Practice Nurse Flu Clinics : arrange at appropriate times of the year [usually April/May].
■Liaison with Doctors discussing overdue tests, immunizations and pap smears. Give
Doctors a list of “jobs” to do weekly to assist Practice Nurse which usually involves ‘tiding up” patient files and printing path forms.
■Monitor Medicare claims of those pts with GPMP’s, TCA’s, reviews and SIP payments.
I developing the role of chronic diseases nurse at our AMS. So all information on job descriptions extra tips and cheat shets would be great to share.I have some great ideas already thanks