Chronic disease management self-assessment · PDF fileChronic Disease Management...

Service Provider:

Service/Program Site: Date:

1

Chronic Disease Management Self-Assessment Tool

This Self-Assessment Tool has been developed to assist service providers to analyse the delivery of the NSW Chronic Disease Management Program – Connecting Care in

the Community (CDMP) against the CDMP Service Model. Completing the Tool will build a better understanding of how the service connects, and delivers quality person

centred care across the range of chronic disease programs and services available to people with chronic disease.

The Tool aligns with the six core elements, of the CDMP Service Model - Targeted Enrolment, Comprehensive Assessment, Shared Care Planning, Care Coordination, Self-

Management Support, and Monitoring and Review - that apply to aspects of quality care for people with chronic disease. Each Service Standard within the Self-Assessment

Tool underpins one of the six core elements, and further defines the provision of appropriate and comprehensive care for the priority population: Aboriginal People.

The CDMP- Service Model also identifies 4 key resources – Governance, Workforce, Reporting and Evaluation and Information and Technology – that ensures systems are

in place to support the delivery of the CDMP’s six core elements. Completion of the Tool will assist service providers to identify and prioritise opportunities to improve the

quality of care for people with chronic disease.

Each Service Standard should be assigned a rating based on the quality of the current service provision. Users are to provide evidence to support their -selected ratings.

Rating Scale

N/A = Not applicable

U = Unsure

NM = Not met

Pl = Planned

PM = Partially met

M = Met

The CDMP Service Model provides a clear statement about the core principles that underpin the quality of care consumers can expect from Chronic Disease

Management Programs in NSW. The principles of the CDMP are to:

Support the provision of coordinated, person-centred care that is empowering and respectful

Enable the primary care sector to manage and support people with chronic disease as close to home as possible, ideally through a ‘medical home’ model

Work in partnership to provide comprehensive and holistic care

Implement evidence-based and evidence-informed care coordination and self-management support

Address health inequities especially for populations known to be at higher risk of hospitalisation

Service Standard Met Partially Met Planned Not Met

All requirements necessary to

implement the Service

Standard components are in

place, and the policy, process

or systems are being utilised

appropriately.

Most requirements

necessary to

implement the Service

Standard components

are in place.

Planning is underway to

progress the requirements

necessary to implement

the Service Standard

components.

Many of the requirements

necessary to implement the

Service Standard

Components are not in place

and are not planned to

commence.

Service Provider:


2

Core Element One: Targeted Enrolment The CDMP enrols people who are most in need and likely to benefit from care coordination and self-management support to help them manage their chronic disease in the

community, reduce their need for acute hospital care and address health inequities. Once a participant is identified for enrolment into the CDMP, a risk assessment is

carried out to determine his or her risk of hospitalisation and the subsequent intensity of care coordination, self-management support and/or referral to other services as

required.

Service Standards Rating Reference Details

1. Automatic electronic prompts/alerts/reports are available to staff and are used to identify eligible participants

2. Documentation and training is available for all staff on use of the electronic prompts, alerts and/or lists

3. There is a single point of access for referrals into the CDMP across the site1

4. The referral process into the CDMP is documented and up to date

5. All relevant providers are aware of the intake/referral process

6. 48 hour follow up has a documented referral process into the CDMP

7. Referrers and patients are notified of the outcome of referrals

8. Aboriginal Health Workers promote the program to Aboriginal communities

9. Written information about the CDMP, eligibility and referral process is available in a variety of modes and languages

10. There are documented guidelines for determination of eligible participants

___

___ ___ ___ ___ ___ ___ ___

___ ___

___

Refer to NSQHS 1.8.1, 1.8.2 6.2.1, 6.5.1 1.7.1, 1.7.2

1.18.2

Document the criteria used to identify eligible participants.

Identify whether community health intake is centralised across the LHD.

List the referral sources for your site

Are you aware of any delays in notifying/providing services?

List what mode and language the information is available in.

Note whether there is information available on the LHD or Medicare local websites.

1 Site: The CDMP may be delivered through multiple sites across an LHD; particularly in rural LHDs. In this circumstance a single point of access per site/facility that delivers

the CDMP; rather than for the LHD as a whole is adequate.

Service Provider:


3


11. A standardised process to stratify a participants’ risk of hospitalisation is used to direct participants to the most appropriate service delivery option2

12. There is a process in place to review whether CDMP participants are referred to the correct service based on the risk stratification process

13. Written or verbal consent is obtained prior to enrolment into the Program, and includes provision of participant brochure

14. ‘Program Consent’ and ‘Program Consent Date’ are recorded electronically There are documented processes for obtaining and recording consent in clinical data management systems

___

___

___

___

Identify what internal processes are in place to monitor/assess health care interpreter use and correct service delivery option. http://www0.health.nsw.gov.au/policies/pd/2006/PD2006_053.html

Provide a copy of the stratification tool used.

Does the stratification you undertake for CDMP

participants include consideration of:

Previous hospital and emergency presentation

Employment status & Aboriginality

Number of co-morbidities & regular medications

Priority Population: Aboriginal People The CDMP seeks to provide person-centred care to populations with higher prevalence of chronic disease, and who are identified as being at higher risk of hospitalisation in

order to address health inequities. These populations experience poorer outcomes due to the disproportionate burden of chronic disease and disadvantage, limited access

to health services and the complexity of their care needs. Populations that are prioritised for enrolment into the CDMP include Aboriginal people.


1. Identification of Aboriginal participants by CDMP staff conforms to AIHW best practice guidelines and Policy Directive 2012-042 , and is mandatory

2. Mandatory Aboriginal identification training is provided for all staff, and attendance is monitored, Policy Directive 2011-069

3. Promotion of self-identification by Aboriginal people is undertaken by CDMP staff

___

___

___

Refer to CCAP Gap Analysis Tool

Survey Part 1

Policy Directive 2012-042: http://www0.health.nsw.gov.au/policies/pd/2012/PD2012_042.html

Policy Directive 2011-069 http://www0.health.nsw.gov.au/policies/pd/2011/PD2011_069.html

2

Service Delivery Option: CDMP participants are stratified into different Chronic Disease Services based on their risk and particular needs. The Chronic Disease Services that are available to

CDMP participants include intensive case management, care coordination, self-management support, telephone based health coaching and cardiac and pulmonary rehabilitation.

http://www0.health.nsw.gov.au/policies/pd/2006/PD2006_053.html






Service Provider:


4

Core Element Two: Comprehensive Assessment Comprehensive Assessment allows for a better understanding of the person’s needs and circumstances to inform care planning. It ensures that all factors affecting a

person‘s health and well-being are made known to facilitate the planning of their care. The Comprehensive Assessment should be evidence informed and enable integrated

care for the participant across primary, secondary and tertiary healthcare settings.


1. There is a documented process to undertake a Comprehensive Assessment

2. All previous assessment information is compiled and a gap analysis performed to determine what elements need to be covered in the Comprehensive Assessment

3. The Principal Care Coordinator3 supports the participant’s primary care provider to complete a Comprehensive Assessment in the absence of existing assessment information.

4. A Comprehensive Assessment tool is used by all staff which covers the physical, social, psychological and cognitive needs of participants

5. A health literacy assessment is undertaken

6. A falls risk assessment is undertaken

7. The Comprehensive Assessment is updated as necessary

8. The Comprehensive Assessment is documented in the electronic client record

9. The Comprehensive Assessment may be viewed by all health professionals involved in the participant’s care

___

___

___

___ ___

___ ___

___

___

Refer to NSQHS 1.9.1, 1.18.1, 1.18.3, 4.6.1,

4.6.2, 4.7.1, 6.2.1, 10.5.1, 10.6.1

Identify what particular guideline, e.g. ONI, the Comprehensive Assessment is based on.

Provide details of the standard Comprehensive Assessment Tool currently in use.

Identify how the completed Comprehensive Assessment is stored and viewed by relevant health professionals.

3

Principal care coordinator: The principal care coordinators central role is delivering and coordinating care for patients, including coordinating care across clinicians, settings, and

conditions/diseases, and helping patients access and navigate the system. The patient can identify their principal care coordinator as being there GP, PN, CDMP Care Coordinator, Local

Health District Rehab clinician

Service Provider:


5


10. The Principal Care Coordinator3 undertakes Comprehensive Assessment at their own facility/rooms or during home visits, as appropriate to the participant

11. There is a documented process for engagement of appropriate professionals/service providers in the Comprehensive Assessment, including support of Aboriginal Health Workers and healthcare interpreters

12. The link between ‘at risk’ behaviour and chronic diseases is described in a way that has relevance to the Aboriginal person and their family context*

13. Appropriate resources that Aboriginal participants will identify with are provided*

14. Appropriate resources that CaLD participants will identify with are provided

15. Resources are appropriate to the participants’ health literacy level

___

___

___

___

___

*Refer to CCAP Gap Analysis Tool

Survey Part 7

Identify what resources are available to Aboriginal and CaLD participants.

Service Provider:


6

Core Element Three: Shared Care Planning The CDMP aims to enable health professionals and service providers to work in partnership to deliver evidence-based, coordinated care. The CDMP brings together multiple

care plans to create a cohesive, comprehensive and person-centred Shared Care Plan that is agreed upon by all care providers, and most importantly by the participant.


1. Participants have a Shared Care Plan developed using a standard template and defined process

2. All previous care plans are compiled and a gap analysis performed to determine what elements need to be updated in the Shared Care Plan

3. The Principal Care Coordinator3 supports the participant’s primary care provider to complete a GPMP or TCA if necessary

4. Shared Care Plans are developed in consideration of the participant’s and carer’s needs identified through the Comprehensive Assessment

5. Shared Care Plans include personal details and diagnosis, list of service providers and referrals, clinical management, self-management goals, medication management plan and guides the care provided at follow up

6. Discharge plans are incorporated into the Shared Care Plan

7. The Shared Care Plan has been developed to support advance care planning and end of life decision making

8. The Shared Care Plan is communicated to all those involved in the participant’s care

9. A copy of the Shared Care Plan is provided to the participant and/or carer and the Primary Health Care Provider

10. Shared Care Plans can be viewed by all health professionals involved in the Participant’s care

11. Shared Care Plans can be updated by the Principal Care Coordinator3 and the Primary Health Provider

___

___

___

___

___

___

___

___

___ ___

___

___

Refer to NSQHS 1.18.1, 1.18.4, 4.13.1, 4.13.2, 4.14.1, 6.2.1,

6.5.1, 9.8.1, 9.8.2, 10.7.1, 10.7.2,

10.7.3

Provide a copy of the standardised Shared Care Plan currently in use.

Describe what support is provided to the Primary Care Provider to complete GPMPs/TCAs.

Provide details on how the current Shared Care Plan is stored.

Note what Health Professionals currently have access to the Shared Care Plan.

Service Provider:


7

Core Element Four: Care Coordination The objective of care coordination delivered as part of CDMP is to achieve better outcomes, support the individual and their carer, and reduce the risk of hospitalisation.

The intensity of care coordination can vary according to the participant’s needs ranging from occasional telephone support to intensive care coordination.

Service Standards Rating Reference Details 1. Participants are allocated a Principal Care Coordinator3

2. The Principal Care Coordinator3 coordinates adherence to evidence based/guideline recommended care

3. There are skilled educators, including Aboriginal Health Workers involved in the participant’s care*

4. There are communication protocols in place between the Principal Care Coordinator3 and all treating and referring health professionals, particularly the primary health care provider through letters, phone calls and/or email

5. There is a data management system (DMS) to support the coordination of care for CDMP participants is available to CDMP staff

6. The DMS tracks the participant’s journey and service usage

7. The DMS supports monitoring/review as outlined in the Shared Care Plan

8. The DMS provides an electronic reminder system for review and follow up

9. Real time alerts are sent to the Principal Care Coordinator3 when CDMP participants present to emergency departments or become inpatients

10. There is a local service directory of services for people with chronic disease

11. There is a mandatory review cycle for the directory

12. Notifications of updates to the directory are sent to all relevant service providers

13. There are documented referral pathways for CDMP participants to other appropriate programs

14. All participants are assisted with appointments and supported in attending referrals, where necessary

___

___

___

___

___

___ ___ ___

___

___

___

___

___

___

Refer to NSQHS 1.7.1, 1.7.2, 6.2.1 1.6.1, 1.6.2, 1.9.1,

1.9.2

Refer to CCAP

Gap Analysis Tool Survey Part 6

Provide details of what services the Principal Care Coordinator provides.

Describe the communication protocols followed by the Principal Care Coordinator.

Provide details of the clinical systems used in the provision of coordinated care.

Identify what internal processes are in place to monitor/assess whether a participant has received the appropriate care.

Provide details of the local service directory.

Service Provider:


8

Core Element Five: Self-Management Support All participants enrolled in the CDMP have access to evidence-based health coaching to empower participants to better manage their conditions. Health coaching supports

both lifestyle risk factor management (weight, physical activity and healthy eating) and disease management based on the person’s Shared Care Plan, and follows the goals

and actions specified in that Plan, developed in partnership by the person and their carer, and agreed by the person’s care providers.


1. Principal Care Coordinator3 works with participants to devise self-management goals based on each participant’s needs, health literacy and readiness to change

2. Self-management goals are regularly assessed and recorded in a standardised way in the Shared Care Plan

3. Self-management goals are accessible to participants/carers and all health professionals involved in participants’ care, as part of the Shared Care Plan

4. Training is available for all staff on best practice self-management strategies

5. Telephone-based health coaching is available

6. Telemonitoring support is available

7. Provide specific materials which describe a participants role in achieving their health goals

8. Appropriate resources that Aboriginal participants will identify with are provided*

9. Appropriate resources that CaLD participants will identify with are provided

10. Consumers/carers provide feedback on resources made available to participants

___

___

___

___

___ ___

___

___

___

___

Refer to NSQHS 1.18.1, 1.18.3, 2.4.1, 4.15.1, 4.15.2, 6.2.1,

6.5.1, 9.7.1, 9.9.1, 9.9.2

*Refer to CCAP

Gap Analysis Tool Survey Part 7

Detail what self-management support training is

available to staff.

Detail who provides the telephone-based health coaching, and how.

Detail the telemonitoring support that is available.

Service Provider:


9

Core Element Six: Monitoring & Review An important component of the CDMP is monitoring the health and health related activities of participants, in partnership with the participant’s primary care provider, to

ensure person-centred care and address health inequities. This is particularly important given participants are not routinely discharged from the CDMP, which is designed to

provide ongoing support to participants as they transition into and out of other Chronic Disease services as appropriate to their needs.

Service Standards Rating Reference Details 1. There is routine follow up of participants, using standard pathways according

to the participants need

2. Responsibility for follow up is assigned to the Principal Care Coordinator3

3. The frequency and content of reviews, determined in the Shared Care Plan, is adhered to

4. There are multiple, flexible options for monitoring and review based on the participants needs

5. Outcomes and actions from follow up are documented in the Shared Care Plan

6. Prompt review where deterioration in a participant’s condition is noted

___ ___

___

___

___ ___

Refer to NSQHS 6.2.1, 9.1.1, 9.1.2

Detail procedures and guidelines for the review and monitoring process, including documenting and sharing processes.

Provide detail as to how follow up is recorded.

Provide detail of your escalation plan.

Service Provider:


10

Resource One: Governance The CDMP promotes a shared governance model at a local level comprising representation from the LHD (CDMP and CCAP), ML, GPs and AMSs, with input from NGOs and

community services (including aged, disability and mental health) where possible. The governance body is able to develop their own key performance indicators and

reporting requirements for CDMP as appropriate.

Enablers Rating Reference Details Strategic Governance 1. A shared governance model at a local level is operating

2. Representation of all key stakeholders on the steering committee

3. There is a mechanism for regular review of membership

4. All members of the Governance body have a shared understanding of, and commitment to the partnership goal among all partners

5. Clear definition and understanding of the roles, responsibilities and expectations of partners

6. Commitment to standardization of common processes across the organisations (e.g. referral protocols, service standards, data collection and reporting mechanisms)

7. There are formal structures for sharing information and resolving disputes

8. There is a local support/advisory group to support better engagement with Aboriginal communities

9. The Aboriginal Health Impact Statement has been completed*

10. There is a mandatory review cycle for undertaking the Impact Statement*

11. A formal communication plan for the CDMP is available

12. Quality improvement activities are embedded into ongoing practice

___ ___

___

___

___

___

___

___ ___

___ ___

___

Refer to NSQHS 1.1.1, 1.1.2, 2.1.1, 1.2.1, 1.2.2, 2.1.2, 2.2.1, 2.2.2, 2.3.1,

2.5.1

*Refer CCAP Gap Analysis Tool Survey Part 2

Identify who is represented on your steering committee (e.g. TOR) eg. LHD (CDMP & CCAP & Hospital/Specialist Services), Medicare Local, GPs, AMSs, relevant community services, consumers and NGOs

Describe formal partnerships that exist to deliver the CDMP (e.g. SLA/MOU).

Describe formal arrangements for engagement (e.g. TOR).

Describe process for initiation and review of Aboriginal Health Impact Statement. http://www0.health.nsw.gov.au/policies/pd/2007/PD2007_082.html

Provide example of the communication plan.

Describe QI process.



Service Provider:


11

Enablers Rating Reference Details

Clinical Governance

1. CDMP service delivery options2 and their structure and content are documented

2. The structure and content of the CDMP Service delivery options2 comply with recommended care

3. Service delivery options2 and their structure and content are regularly reviewed

4. There are documented processes for transitioning people between Chronic Disease services

5. Clinicians are supported in their delivery of evidence based/guideline recommended care

___

___

___

___

___

Refer to NSQHS 6.2.1, 9.1.1, 9.1.2, 9.4.1, 9.4.2, 9.4.3,

9.5.1

Describe you service delivery options and how they are documented.

Describe how people transition between Chronic Disease services.

Explain how this is captured in your CDMP Data Management system.

Describe how clinicians are supported (e.g. Professional development).

Identify whether your LHD or SHN has an Osteoporotic Refracture Prevention Service, and how you transition appropriate CDMP participants into this Service.

2 Service Delivery Option: CDMP participants are stratified into different Chronic Disease Services based on their risk and particular needs. The Chronic Disease Services that are available to

CDMP participants include intensive case management, care coordination, self-management support, telephone based health coaching and cardiac and pulmonary rehabilitation.

Service Provider:


12

Resource Two: Workforce A workforce with sufficient skills and capacity is needed to provide evidence-based, person-centred care for people with chronic disease to enhance and connect Chronic

Disease services for people enrolled in the CDMP. The CDMP workforce enables the primary care provider to deliver continuity of care across primary, community and

acute settings. CDMP positions should align with other local chronic disease initiatives such as disease specific rehabilitation, Closing the Gap and CCAP.


1. The CDMP is fully staffed

2. Staffing includes credible, skilled care coordinators for Aboriginal people, preferably Aboriginal Health Workers

3. Documented CDMP Care Coordinator position descriptions are available

4. There is a mandatory review cycle for the Position Descriptions

5. Completion of annual mandatory training programs is supported and monitored

6. Provision of cultural respect training, with specific attention paid to the link between at risk behaviours and chronic disease and its relevance to the Aboriginal participant and their family/community, in accordance with Policy Directive 2011_069*

7. Dedicated involvement of Chronic Care staff in the provision of professional development for primary care providers

8. Self-Management Support training is provided

___

___

___

___

___

___

___

___

Refer to NSQHS 1.3.1, 1.3.2, 1.3.3,

1.10.1, 1.4.1, 1.4.2, 1.4.3

*Refer CCAP Gap

Analysis Tool Survey Part 7

Please note number of CDMP funded positions, category and location

Number Category Location

Provide a copy of the CDMP Care Coordinator PD.

Policy Directive 2011_069 http://www0.health.nsw.gov.au/policies/pd/2011/PD2011_069.html

Provide details of training courses offered

Describe who was targeted for the training



Service Provider:


13

Resource Three: Reporting & Evaluation To support program evaluation and quality improvement standardised data collection and analysis of the CDMP is required. This will support the delivery of appropriate

service enhancements and ensure demonstrable results are identified not only at an LHD, but State level.


Reporting 1. Minimum Data Set is completed and can be electronically extracted for all

enrolled CDMP participants 2. Quarterly reports are completed, in the agreed format, and submitted

___ ___

Details how this process is embedded in current clinical systems.

Evaluation

3. Ability to capture relevant participant and service provision data/outcomes: a. Health outcomes/functional status, may include:

i. Repeat SF-1 b. Health service utilisation, may include:

i. PPHs: as defined by AIHW (2008)

ii. Readmission: unplanned, within 28 days

iii. LOS: for PPH admissions and/or disease groups

iv. Total bed days: for PPH admissions and/or disease groups

c. Participant satisfaction is measured

d. Participant quality of life is measured

e. Staff and stakeholder satisfaction is measured

___

___

___

___

___

___

Refer to NSQHS 1.20.1, 1.13.1

Define what data can/is being captured.

Service Provider:


14

Resource Four: Information Technology Information Technology (IT) infrastructure is crucial for supporting the operations of the CDMP and facilitating access to relevant up-to-date information about participants.


1. All Chronic Disease services access electronic patient records

2. There are electronic referral processes into the CDMP

3. Electronic data collection system captures and extracts the Minimum Data Set

4. Electronic communication system developed to ensure communication between service providers, including General Practice, ACCHS, AMS, Community Health and Local Health Districts, and the participant

___

___

___

___

Refer to NSQHS 1.9.9

Please define how this is utilised by the CDMP.

Describe how the internal referral processes work.

Define the system being used.

Note what communication system is being used.

Chronic disease management self-assessment · PDF fileChronic Disease Management...

Documents

Transcript of Chronic disease management self-assessment · PDF fileChronic Disease Management...