In Your Practice - Western Sydney Diabetes · In Your Practice Diabetes Case Conferencing Diabetes...
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Improving Diabetes Care In Your Practice Diabetes Case Conferencing Diabetes is the single greatest health challenge faced by residents of Western Sydney. Case conferencing can assist GPs to better manage patients who present with diabetes. The result will be better care for patients with diabetes and a reduced burden of disease in the future. Early evaluation of the case conferencing program shows the team approach to diabetes care has favourable effects on average blood glucose, blood pressure, weight reduction and lipid profile. Case conferencing gives you access to diabetes clinical staff including endocrinologists, registrars and diabetes educators in your practice. Take advantage of the additional support of online HealthPathways and a GP support line if you have any questions. We encourage you to join our network of western Sydney GPs and use case conferencing to improve our management of diabetes. The Aim of the Program • Provide integrated diabetes management in the General Practice setting • Answer diabetes related clinical questions • Provide learning opportunities and increase confidence in managing diabetes • Provide education for practice nurses 3% 25,800 People Diabetes with high comorbidity 12% 103,200 People Diabetes with low comorbidity 35% 301,000 People High risk of Diabetes 50% 430,200 People Healthy
Transcript of In Your Practice - Western Sydney Diabetes · In Your Practice Diabetes Case Conferencing Diabetes...
Improving Diabetes Care In Your Practice
Diabetes Case ConferencingDiabetes is the single greatest health challenge faced by residents of Western Sydney. Case conferencing can assist GPs to better manage patients who present with diabetes. The result will be better care for patients with diabetes and a reduced burden of disease in the future.
Early evaluation of the case conferencing program shows the team approach to diabetes care has favourable effects on average blood glucose, blood pressure, weight reduction and lipid profile.
Case conferencing gives you access to diabetes clinical staff including endocrinologists, registrars and diabetes educators in your practice. Take advantage of the additional support of online HealthPathways and a GP support line if you have any questions.
We encourage you to join our network of western Sydney GPs and use case conferencing to improve our management of diabetes.
The Aim of the Program• Provide integrated diabetes management in the General
Practice setting
• Answer diabetes related clinical questions
• Provide learning opportunities and
increase confidence in managing diabetes
• Provide education for
practice nurses
3%25,800
PeopleDiabetes with
high comorbidity
12%103,200 People
Diabetes with low comorbidity
35%301,000 People
High risk of Diabetes
50%430,200 People
Healthy
1200 GPs in WSLHD
could improve diabetes care
in their practices through participation
in Diabetes Case Conferencing
124 GPs within
the WSLHD catchment areas have
participated in Case
Conferencing
50% of the GPs
recently returned the evaluation
forms assessing the benefits of Diabetes Case Conferencing
FACTS: DIABETES CASE CONFERENCING
“This has been an excellent program. Each patient was discussed in a team approach and changes were made and put into place. A plan was arrived at. It provided excellent teaching for me as a GP and has improved my confidence in managing diabetes. It was a real eye opener in some cases which will result in better care in all diabetic patients”
Dr Toby Nasr, Metella Road Family Practice
What are the benefits to my practice?1. Increased confidence in managing patients with diabetes in
the primary care setting
2. Early evaluation of the program show HbA1c reduction of 0.87%, weight reduction of 1.9Kg, and favourable effects on blood pressure and lipid profile
3. Access to billing for MBS chronic disease items for case conferencing, GP Management Plans, Team Care Arrangements and items of Diabetes Cycles of Care, as eligible
4. Involved GPs reported high satisfaction with case conferencing
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“The mere fact of discussing such
complex cases with Glen (endocrinologist) proved
to be invaluable. We were able to exchange
ideas, Mx strategies and it was very welcoming, most of all the VIP (the patient) being included
in the management was the crowning glory!”
Dr S Seelan, Bridgeview Medical Practice
98% of clinicians surveyedrecommend Diabetes CaseConferencing to a colleague
Case conferencing gives you access to:Endocrinologist and Diabetes Educator Visiting Your Practice for Case Conferencing: A multidisciplinary case conferencing format is utilised to consult with patients identified by your practice as being able to benefit from integrated diabetes management. The Endocrinologist and the Diabetes Educator (if required) accompany the General Practitioner and another allied health professional (e.g. your Practice Nurse). This occurs in the General Practitioner’s rooms. For more information and to book a case conference session speak to your practice’s WentWest Practice Support team member or call the WentWest Help Desk on 02 8811 7117.
Additional services:Diabetes Outpatient Clinics: We have discharged many of our patients with diabetes requiring routine care back to General Practice once stabilised, so we are more available to help with the complex cases in our Diabetes Clinic. Waiting time for the Diabetes Clinic is now really short so you can take advantage of this.
HealthPathways: For management guidelines and referral information you may wish to refer to western Sydney HealthPathways. Developed jointly by primary and secondary care clinicians, HealthPathways is an online tool designed for use by clinicians with an emphasis on primary care. The pathways are maps of local health services and resources (including publicly funded services).
Please visit: http://westernsydney.healthpathways.org.au Login: health Password: w3stern
GP support line: If you have patient management or other program questions you may wish to call the integrated care GP support line on 1300 972 915 and select “Diabetes” + “Blacktown”.
Western Sydney Diabetes Case Conferencing Program | 3
Coordination of a Diabetes Case Conference with a multidisciplinary team of at least two other formal care providers
Description Conference Time Item No Medicare Fee
Attendance by a medical practitioner (including a General Practitioner, but not including a specialist or consultant physician), as a member of a case conference team, to organise and coordinate a case conference in a Residential Aged Care Facility OR a Community case conference OR a discharge case conference (not being a service associated with one to which items 721 to 732 apply)
At least 15 minutes and less than 20 minutes 735 $70.65
At least 20 minutes and less than 40 minutes 739 $120.95
At least 40 minutes 743 $201.65
General Practice MBS Item Numbers for Care Plans
DescriptionItem No
Recommended Frequency
Min Claiming
Period
Other CDM item numbers that can/not be claimed in
conjunction
Can Cannot
Preparation of a GP Management Plan 721 2 yearly 12 months 723 735, 739, 743
Coordination of Team Care Arrangements 723 2 yearly 12 months 721 735, 739, 743
Review of a GP Management Plan or Coordination of Review of Team Care Arrangements / Multidisciplinary Community Care Plan / Multidisciplinary Discharge Plan
732
When the GP determines
this is clinically appropriate
3 months 732 735, 739, 743
Contribution to a multidisciplinary care plan or Team Care Arrangements 729 6 months 3 months
735, 739, 743, 721, 723, 732
“Overall it’s very good idea; patients and Dr’s both parties are happy in terms of control [of] the diabetes, prevent the complications which would definitely reduce the number of hospital admissions, consequently better health outcome. Cost effective. Effective time management as well.”
Dr Lumina Titus, Bridgeview Medical Practice
“It was the best opportunity for me to share my concerns re proper treatment of my diabetes patients with the group of experts. I would like to have this opportunity in future.”
Dr Atig Mehraby, Winston Hills Medical Centre
“This is a great platform/environment to address “difficult or non-compliant” patients with poorly controlled diabetes. It gives the GP the support and backup to initiate changes to improve their poorly controlled diabetes.
We have had positive outcomes from the 1st case conference.”
Veronica Dingle RN, CDE Eastbrook Medical Centre
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Frequently Asked Questions
Q: Who needs to be present for the case conferences?
A: The General Practitioner, Endocrinologist plus another allied health professional (either a Diabetes Educator, Dietician, Exercise Physiologist or Practice Nurse) and the patient – who may like to bring a support person with them (a spouse or family member).
Q: Will the Endocrinologist be taking over the patient’s overall diabetes care and management going forward?
A: No. The case conference will not replace normal diabetes management in the practice; it is to discuss management issues and treatment options.
Q: How long will each case conference take? A: Each case conference will take approximately
30 minutes
Q: Will there be any cost to the practice? A: There is no cost to the practice. The GP can bill a
case conference item number that is time based. As most consults last for approximately 30 mins, this item number is 739. (Refer to page 4).
Q: Will there be any cost to the patient? A: No. The practice will usually bulk bill the
patient using the appropriate item number shown on page 4. The Endocrinologist will also bulk bill the patient for his/her time.
Q: What is the planned follow-up? A: The GP will follow up the care and assess the
control following any suggested change in management. It will be possible for the practice to organise follow-up case conference sessions where specific cases can be reviewed or new cases presented.
Q: What if the patient already has an Endocrinologist?
A: The Endocrinologist involved in Case Conferencing works closely with colleagues within the Western Sydney Local Health District. They are aware of the program and support the principle that a patient with diabetes can be best supported in the primary care setting (General Practice). All recommendations provided by the Endocrinologist in regards to the patient’s ongoing management are based on current clinical best practice indicators. No patient management will be changed unless all health practitioners involved in the case conference, including the patient, agree.
Q: Can the Allied Health Professional and Practice Nurse sit in on the case conference?
A: Absolutely. The case conference is an opportunity for learning and sharing knowledge and encouraging a team approach. We welcome involvement from the AHP and PN.
Q: How do I access this service and set up appointments?
A: Your Practice Support Coordinator from WentWest will act as a liaison between your practice and the other health professionals involved in the program. They will assist you with all of the paperwork required and knowledge about patient identification, bookings and MBS billing. Alternatively you can contact the diabetes educator to discuss booking a case conference (refer to page 8).
Q: Does my practice need to be enrolled with Integrated Care Program in order to have a diabetes case conference and does the patient need to be complex?
A: Diabetes case conference can be organised for any practice, and the team is happy to review people at all stages of diabetes ie. from pre-diabetes to complex needs.
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FEEDBACK: 43 CLINICIANS FEEDBACK ON DIABETES CASE CONFERENCING
The main benefits of Diabetes Case Conferencing to you and your patients
“ Better diabetes control; enhance and enforce my clinical care; easy access to specialist clinic without cost to patient + Follow-up of patients has been extremely helpful in reinforcing their adherence and improvement of diabetes control”
Strongly agree Agree Neutral Diasgree Strongly Disagree
“ Allows a team approach to care with expert input in a very timely & relevant manner. Allows better diabetic control earlier”
“ Useful service for patients in a trusted and convenient environment, supporting and enhancing continuity of care”
The Case Conference provides an
interactive learning experience?
The experience will decrease my
referrals to the diabetes centre or endocrinologist?
The Program improves the
relationship and communication between the GPs
and specialist?
The experience has improved
my confidence to manage diabetes?
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Would a follow up clinic
be beneficial?
Would you recommend the program to a colleague?
“ GP’s point – able to clarify complex matters, showed patient that we cared; increased invaluable knowledge”
Yes
No
Yes
Uns
ure
“ They [patients] feel confident that their GP & specialist are sitting together to sort this problem in front of them”
“ Main benefit is having endocrinologist & diabetes educator coming to the practice/one on one approach”
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Endocrinologist Professor Glen F Maberly Senior Staff Specialist (Endocrinology) Program Lead, Western Sydney Diabetes Initiative Western Sydney Local Health District (WSLHD) Tel: 02 8670 0014 | Mobile: 0451 991 553 Email: [email protected]
Specialist Consulting in Endocrinology and Diabetes and working with partners in the District including Western Sydney LHD and WentWest to enhance the model of care for diabetes.
Senior Endocrine RegistrarDr Rajini Jayaballa Senior Endocrine Registrar (Community) Blacktown and Mount Druitt Hospitals WSLHD Mobile: 0437 619 609 Email: [email protected]
Dr Rajini Jayaballa is a Senior Endocrine Registrar at Blacktown and Mount Druitt Hospitals, with a special interest in the management of diabetes
Credentialled Diabetes EducatorSiân Bramwell RN, RM, Diabetes Educator Western Sydney Local Health District Tel: 02 8670 0016 | Mob: 0410 299 958 Email: [email protected]
Siân Bramwell is a Credentialled Diabetes Educator working as a Community Diabetes Nurse Educator for WSLHD and supporting General Practices with diabetes management.
Resident Medical OfficerBlacktown and Mount Druitt Hospitals
Dedicated RMO position with rotation of staff every 10 weeks
How do I get involved?Contact:
1. WentWest Practice Support Coordinator or the Help Desk on 02 8811 7117
2. Community Diabetes Nurse Educator, Western Sydney LHD, Siân Bramwell, on 0410 299 958 or email: [email protected]
What is required of the GP?• A written referral for each patient
• Patient consent for each consultation
• Completion of an evaluation form
• GP bills MBS Case Conferencing item number
PROFILES:
