The rise and rise of the chronic care coordinator
The people at Mt Barker/Balhannah Medical Clinic in South Australia were part of the second wave of the Collaborative back in 2005. They remind us that “care redesign” is one of the pillars of effective chronic care. That is you can’t keep doing the same thing and expect different results!
What did they do? Like many of the successful practices in the collaborative they created a new creature –the chronic disease coordinator.
“We have made quite a few changes but I believe the most significant change was brought about by employing a Registered Nurse to co-ordinate chronic disease management.
The first plan we tried was to have the nurse identify our patients with high HBA1C levels and invite them to a diabetic clinic which involved the clinical nurse, diabetic educator and doctor with an appointment at a later date with the podiatrist if indicated.
Now rather than running a dedicated diabetes clinic our nurse manages the recall of our diabetic patients in order to complete cycles of care (and achieve PIP recognition). She is adept at checking appointment schedules to achieve these outcomes.
Our doctors are now much more opportunistic and will identify patients who present with “risk” factors. These patients have the necessary tests ordered and see our chronic care coordinator, with the doctors signing off after consultation and planning. She also performs home health reviews and identifies those who may benefit from home medication reviews. Other functions include following up our outstanding pathology results – making sure all patients have been notified of abnormalities and irregularities and ensuring they have appointments to discuss their results with their doctor. From these patients she will make appointments if indicated by doctor and accepted by patient, for chronic disease management.
In our Practice of six – seven doctors, the demands of clinical nursing were increasing rapidly. By using our Chronic Disease Management Nurse we were able to rethink how we addressed our patients’ needs, we had more time to look at being much more pro-active in seeking out patients who were at risk.”
By making chronic disease care an explicit, resourced, “job-descriptioned”, core part of their way of working general practices like Mt Barker/Balhannah Medical Clinic are leading the way.
Mary Howe from the practice added a comment (see below) about how the practice have developed a tracking sheet for each patient having a ‘plan’ to ensure the whole process from identifying the patient, through to billing is completed. Mary has shared generously and included the tracking sheets for GPMP/TCA and DMMR items.
Mary writes:
"It would be easy for any Practice to create their own tracking sheet. We print these tracking sheets and keep them in a folder. The progress of the items on the tracking sheets are regularly checked by our co-ordinator to see if they have been completed and all the steps have been followed.
The sheets provide opportunity for continuous monitoring and once all the steps have been completed we just destroy them. If the co-ordinator is away then staff / doctors can access the sheets to see where the specific items are up to.
We do not specify who is responsible for each of the steps as we are all
aware of our roles, but a Practice could name the person / department
responsible for completion of each step to ensure staff understand the
role they play in the process.
I hope this small initiative helps others in the complex world of
Chronic Disease Management."
The Doctors of Ivanhoe tracking sheets are available from the links below:
- GPMP / TCA Tracking Sheet (pdf version)
- GPMP / TCA Tracking Sheet (spreadsheet xls version)
- DMMR Tracking Sheet (pdf)
Have you redesigned your practice to include a chronic disease coordinator role? Make a comment and share your good idea below.
I totally agree in the idea of a CCC - at the moment with us, it is a job shared between the clinic manager, practice nurse and enrolled nurse and some of the doctors!
Cheers Jenni