Diabetes Practice Nurses SA Chronic Disease Management Good chronic disease management requires: awareness of your patient demographics, whats affecting who? knowledge of the specific disease state, what is it all about? program / plan, how am I going to do it? up-to-date resources incl. templates, what am I doing with it? recall and reminder system, what now? Awareness Knowing your patients/demographics. General awareness, eg. aging area v younger population, this will affect who you are targeting and how you will target. PENCAT Tool, and some data extraction through clinic software Knowledge Having an understanding about the disease state. Background understanding is a great place to start, increasing on your knowledge increases the amount you can impart with a patient. Transitions from being an information session to a time of providing education. Program / Plan How much time has the clinic dedicated to care planning What resources are available eg, room and equipment Are reception staff involved /aware? All all GPs involved in care planning? How many patients will be seen per session, how are they going to be followed up with GP? Resources Patient handouts some will take home information and read it Direct patients to various websites some are interactive Posters & models some people are more visual/textual learners Dont be shy about asking for patient information, but also dont be shy about not taking it either Templates do they fit your practice? Medical software has some available, as well as local divisions GPNS, ANPGP Also, you can develop your own. Templates Explained the steps involved, and the patient has agreed Identify and/or confirm diagnosis Agreed management goals Identified agreed actions Identified treatment options / services (TCA) Date for review. Billing Item numbers are there to be billed. Medicare has documented the item number / billing information in a complicated manner Ultimately: New Plan + TCA Review Review + Diabetes Cycle of Care New Plan + TCA + Cycle of Care + ECG Recalls Medicare suggests reviewing patients every 6 months, but item numbers are claimable at 3 months. A recall system is something that needs to be tailored to each clinic, but some things to consider may include: staff availability, who is generating letters, making phone calls patient preference, do they respond to letters or phone calls better Thank you for time this evening Donna vonBlankensee RN grad.cert cdsma c.d.program.development P: E: W:F: Practice Nurses SA