The team at Doctors Grand Plaza have had great success with their version of the patient held health summary – “the blue folder”

Melissa Cahill tells their story.

Our finest achievement conceived through the collaborative process is our “blue folder”. The blue folder is our version of the hand held record and the patients are encouraged to take it with them to specialist appointments, allied health appointments or to the ED if they need to present there.

In this is a copy of

• the patient’s medical history,
• current medication,
• allergies,
• immunisations,
• management plan,
• recent results (bloods, x-rays, echos etc) and
• current ECGs or ABIs.

The management plan also includes our invention – “the care calendar” (something I know that Tony’s practice has stolen shamelessly). The care calendar is a one paged three columned monthly calendar that sets out what needs to be done by the patient and the doctor for each month. The three columns include last year, this year and the next year. That way I can see what has been done when (i.e. the patients last yearly eye check was in Aug 2008 so it must be due again in Aug 09). and what is due to come before they are seen in 3 months time (i.e. we are seeing the patient in October and their ophthalmology appointment is due in November so a referral should be done at the October visit) and what is due in the future (i.e. their follow up colonoscopy or pap smear is not due til next year).

If updated correctly and regularly (I try to update the calendar even when I get a specialist letter telling me the patient is due to see them in 6 months), it is an easy way to know what is due when (without going through screens of old notes and blood results) and helps keep the patient organised as well (I derive great pleasure when the patient tells me when their blood tests are due rather than the other way around).

We continually get great feedback via the patients from the hospitals about our folder. One of my regular patients came in to see me today. We had tried very hard to sell him the idea of the blue folder but he finally took it in with him when he saw a physician at the PAH. He told me with great pride that the physician and the registrar poured over the folder with its depth of information like “piranhas” and that the comments they gave were “impressive” and “every doctor should look after their patients like this”.

Needless to say that made me quite proud and ensured that he would continue to take his blue folder to all his specialist appointments in future.

Melissa has been kind enough to share an example of their care caendar at this link.

Are you using a patient held record? Have you found it useful? What do you include? Have you any sample pages to share?

Have you ever worked out the steps involved in completing a GP Management Plan and Team Care Arrangement?

The Doctors of Ivanhoe have mapped this process, and produced a Tracking Sheet to assist in making sure each step is completed.

Mary Howe from the practice added this comment to our story on Chronic Care Coordinators.

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 doesn’t complete their part, the plan may not get completed (nurse time wasted), the item doesn’t 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.

Since then many have asked for a copy of the tracking sheets used in the practice.

Mary writes

Please find attached our tracking sheets for GPMP/TCA and DMMR items.

It would be easy for any Practice to create their own. We print these tracking sheets and keep them in a folder. The progress of the items on the tracking sheets are regularly checked by our co-ordinator to see if they have been completed and all the steps have been followed.

The sheets provide opportunity for continuous monitoring and once all the steps have been completed we just destroy them. If the co-ordinator is away then staff / doctors can access the sheets to see where the specific items are up to.

We do not specify who is responsible for each of the steps as we are all
aware of our roles, but a Practice could name the person / department
responsible for completion of each step to ensure staff understand the
role they play in the process.

I hope this small initiative helps others in the complex world of
Chronic Disease Management.

Thanks for sharing generously, Mary.

The Doctors of Ivanhoe tracking sheets are available from the links below:

• GPMP / TCA Tracking Sheet (pdf version)
• GPMP / TCA Tracking Sheet (spreadsheet xls version)
• DMMR Tracking Sheet (pdf)

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.