NSW Chronic Care Program
Strengthening general practitioner involvement in chronic care
General practitioners have a key role to play in providing well-coordinated
chronic care as part of a multi-disciplinary team. They are generally
the initial point of contact for people with chronic illnesses and play
a key role in prevention, diagnosis and management of chronic disease
in the community. Their role and workload are being increasingly impacted
upon by the growing focus on supporting people with chronic illnesses
in their home and community environment.
Identifying and implementing essential factors for success in engaging
general practitioners and NSW Divisions of General Practice to improve
the of care of patients with chronic conditions is an important initiative
of phase two of the NSW Chronic Care Program. Strengthening
general practitioner involvement in chronic care: Review and recommendations
and Executive
Summary identified successful strategies, challenges and barriers
for Area Health Services, Divisions and general practitioners to work
together to improve the continuity of care for patients with chronic diseases.
The Strengthening the integration of general practice project is
a result of the report's recommendations and is currently currently funding
the following projects across NSW:
Barrier Division of General Practice (Greater Western Area Health
Service) - Chronic Care Links
The project will recruit a Chronic Care Links Nurse to improve delivery
of best practice care between the hospital and community, and improve
communication and co-ordination across all sectors. The project will apply
the effective processes developed by the successful Regional Diabetes
Centre to other chronic illnesses. The Regional Diabetes Centre has been
operating since 1997 and is jointly funded by Greater Western Area Health
Service and the Barrier Davison of General Practice. It has demonstrated
impressive results with improved health outcomes through effective collaboration
and integration, and 100% of local general practitioners refering to and
using the service.
Barwon Division of General Practice and New England Division of General
Practice (Hunter/New England Area Health Service) - Diabetes Integrated
Care Program Information System - D_info
Diabetes is a key priority in the region and both the Barwon and New England
Divisions of General Practice have strong, successful diabetes programs
currently implemented. The project proposes to design and implement an
information system (D_Info) that will allow the exchange of clinical information
between general practitioners, community health staff (primarily the diabetes
educator), pathology services and specialist staff at the Diabetes Centre.
It is anticipated that collaboration involved in the development of D_Info
will support the delivery of integrated multidisciplinary care for patients
with diabetes and associated conditions.
Dubbo Plains Division of General Practice (Greater Western Area Health
Service) - Enhancing Continuity of Care for Patients with Chronic Illness
The aim of the project is to improve the continuity of care for patients
with chronic illness who are discharged from Dubbo Base Hospital. Poor
communication and transfer of patient information between Dubbo Base Hospital
and general practitioners has been identified as a key issue needing to
be addressed for people with chronic illness in the region. A registered
nurse/project coordinator will be employed to review of current discharge
processes through consultation with stakeholders and implement the revised
processes and communication systems.
Mid North Coast Division of General Practice and Hastings Macleay Division
of General Practice (North Coast Area Health Service) - North Coast
Diabetes Integrated Care Program
Diabetes is one of the main priorities for the new North Coast Area Health
Services Plan. This is a joint proposal between the two divisions and
the Area Health Service, to collaboratively develop integrated models
of care for patients with diabetes and associated conditions and overcome
the historic fragmentation of services across the tertiary, acute and
primary care sectors. It is intended that this initiative be expanded
to chronic disease care and management.
NSW Central Coast Division of General Practice (North Sydney/Central
Coast Area Health Service) - Partners in Health - enhancing chronic
disease management in General Practice
The project aims to develop a sustainable model of strengthening general
practitioner involvement in chronic care and promote best practice diagnosis
and management of chronic disease. A Chronic Disease Management Clinical
Coordinator will be jointly funded by this project and the Central Coast
Division of General Practice to promote continuity of care between Area
Health Services, general practice and other key service providers. The
Coordinator will focus on strengthening clinical pathways between hospital
and community, promoting chronic disease self-management, increasing support
to general practitioners, improving general practice infrastructure and
aid the provision of up-to-date information for all patients.
Shoalhaven Division of General Practice (Greater Southern Area Health
Service) - Breathe Easy, Live Well
The Breathe Easy, Live Well project is designed to encourage collaboration
between general practitioners and hospital services (such as, the emergency
department, hospital specialists and chronic care with integrated primary
care services) to improve the coordination and quality of care of people
with chronic obstructive pulmonary disease and congestive heart failure
in the Shoalhaven community. Consultation with relevant stakeholders will
identify barriers and develop shared goals, protocols, new pathways, referral
processes and systems for feedback and information sharing to improve
diagnosis, management and prevention of chronic obstructive pulmonary
disease and congestive heart failure, smoking cessation, immunization
and care planning.
South East NSW Division of General Practice (Greater Southern Area
Health Service) - Coordinated Community Based Care Planning in the
Eurobodalla area
The project aims to develop sustainable links between Area Health Service
community health staff, patients with cardio-vascular disease (CVD) and
chronic obstructive pulmonary disease (COPD) and the patient's usual general
practitioner. A comprehensive patient self-management and care planning
system will be implemented. Community health staff and general practitioners
will be trained in the Flinders self-management approach at the point
of service. Allied health staff will actively engage general practitioners
in multidisciplinary care. The general practitioner will have access to
this team through a central referral system with one point of contact,
reducing the complexity of referring and communicating with several team
members.
South Eastern Sydney Division of General Practice (South Eastern Sydney/
Illawarra Area Health Service) - Patient Self-Management in Cardio-Vascular
Disease and Chronic Obstructive Pulmonary Disease for Patients of General
Practices in South Eastern Sydney Division of General Practice
This project encourages early general practitioner referral of patients
with cardiovascular disease (CVD) and chronic obstructive pulmonary disease
(COPD) to specialist Area nurse educators. General practitioners in the
region have developed excellent relationships with the Diabetes Educators
at the Diabetes Centre and find their help in training patients in self-management
beneficial to managing the patient's care. This successful model will
be used to improve the linkages between the Divisions' general practitioners
and the existing programs in heart disease and respiratory medicine. Sustainable
pathways of care for CVD and COPD will also be developed during the project.
For further information or to subscribe to the Chronic Care Listserve
please contact the NSW Chronic Care Unit on 02 9391 9921 or email chroniccare@doh.health.nsw.gov.au.
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