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
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.
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: