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.