Programs - Chronic Disease Management

Australian Primary Care Collaboratives Program

Program Manager - Maureen Thornhill - Phone: (02) 6884 0197 

This program is funded through the Commonwealth Department of Health and Ageing and delivered via the Improvement Foundation Australia.

The objective of the program is to encourage and support general practices throughout Australia in delivering rapid, measurable, systematic and sustainable improvements in the care they provide to patients, through the sound understanding and effective application of quality improvement methods and skills.

More than 600 practices have participated in the Collaboratives since 2005 and another 1000 have been given the opportunity during 2008/2009. Oustanding success has been demonstrated in improving patient outcomes and practice systems, with particular regard to diabetes, coronary heart disease, and patient access to timely and effective care.

The Collaborative Approach to Chronic Disease Management

Effective management of chronic disease is the major challenge facing all health systems. To improve the care we provide, WE NEED TO FOCUS ON THE SYSTEMS IN OUR PRACTICE. We need better tools, teams, and processes if we are to manage the growing demands on our services effectively. During the journey of the APCC program we have been learning better ways of delivering care in chronic disease but the 'best' model in the Australian context is still a work in progress. The following are key features of the Collaborative approach and these have grown out of the work done by participating practices:

• care is patient-centred
• care is holistic
• care is proactive
• care is team-based
• care is integrated
• care is systematic
• care is accessible

APCC Program in the Dubbo Plains Division

This Division has just had two (2) practices in Dubbo and one (1) practice in Coonamble complete 18 months on a State based Wave of the program. As of October 2009 there are now another 11 practices in the region that have commenced a local wave - they are required to submit monthly data to an online reporting system for the next 18mths.

The 3 focus areas in each practice are:

1. Improved Access and Care Redesign  - AIM: 90% of patients should be able to access their primary healthcare professional of choice on the day of their choice 
2. CHD - AIM: 30% reduction in mortality of patients with CHD in three years 

3. Diabetes - AIM: 50% of patients with diabetes type 1 or 2 within participating practices should have an HbA1c of 7.0 or less

The aim of the access and care redesign focus is to improve the interactions you have with patients and your practice team, so that:

• Delays in the system are reduced
• Practice efficiency is increased
• Patient outcomes are improved
• Practices are more sustainable
• Patient, staff and doctors are more satisfied 

The aims of the CHD and Diabetes focus are to ensure each practice can establish and maintain disease specific registers and associated patient management including making the most of the MBS initiatives. It involves a lot of data cleaning as part of the process.

Data Cleaning

The Division will install a data extraction tool (either the Canning Data Extraction Tool or the PEN Clinical Audit Tool). These tools allow you to review your current diabetes, heart disease and asthma lists, etc. While doing this you can review what data is missing and sort your patients according to HbA1c levels and blood pressure or other results which then allows you to pinpoint appropriate recalls and plan your resources accordingly. This is a free service offered by the Division and will not affect your clinical data systems.

Other components of data cleaning include deactivating deceased patients routinely, deactivating patients who have not presented to the practice in last 3 years and ensuring that processes are put into place to sustain ongoing data cleaning. Data cleaning also involves the establishment of diabetes and other disease specific registers as well as cleaning up outstanding requests and recalls. Through the use of the data extraction tool your practice can monitor it's progress. 

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