Jane Calligeros, Founder and CEO CDM Plus
My Care Plan is a patient resource that can help GPs and Health Professionals empower patients to self-manage their chronic conditions so they can stay well and out of the hospital. Chronic conditions are often lifelong and include diabetes, cardiovascular disease, asthma, COPD, chronic kidney disease, depression, anxiety, cancer, stroke, osteoarthritis, and osteoporosis.
Increasing self-management is the key to improving patient outcomes with chronic conditions. Many chronic conditions have overlapping self-management strategies, including lifestyle modifications, medicines, and monitoring observations and symptoms. As health professionals, we can help increase patient knowledge and skills and support patients as they implement self-management strategies. When unwell patients present to primary care centres or hospitals, they are triaged into a category based on their presenting problem, observations, and symptoms. My Care Plan features an escalation protocol or ‘patient triage’ to help patients and their families or carers recognise when they need help.
My Care Plan has simplified patient self-management into four sections:
1. Learning about My Conditions can help me self-manage – By assisting patients to learn about their chronic conditions, we can empower them to become more engaged in their care. Recording observations and symptoms can help patients self-manage by connecting how they are feeling with their chronic conditions.
2. I know My Targets and have set My Goals and My Tasks – Self-management takes a bit of practice and lots of planning, and as health professionals, we can help patients set up targets for their chronic conditions. Distinguishing between target, high, and low observations and connecting these readings with symptoms can increase knowledge and help patients self-manage.
3. I know when to Contact My GP if I’m feeling unwell – Recognising when someone is unwell is a vital part of self-management. If patients can recognise important signs and symptoms, they can help reduce preventable hospitalisations by seeking early treatment from their GP.
4. I know when to Call an Ambulance or go to the hospital if I’m feeling very unwell – Hospitalisations are a burden on our health system, and many of the common presentations are due to common chronic conditions. We can help reduce preventable hospitalisation by helping patients and their families or carers recognise the signs and symptoms earlier.
The number of patients with chronic conditions is increasing; almost half of Australians have one or more chronic conditions (Australian Institute of Health and Welfare, May 2021). Chronic disease management can be overwhelming for health professionals, patients, and their families. Chronic conditions place an enormous burden on the resources in primary care, and many general practices need more resources to manage the increasing number of patients. Self-Management can take time, and My Care Plan helps patients increase confidence while maintaining regular reviews with GPs and other Health Professionals.
In primary care, chronic disease management (CDM) involves a series of planned appointments throughout the year. A patient will usually attend the practice for an appointment with the CDM Nurse or Aboriginal Health Worker and the GP to prepare a management plan (GPMP) for the next 12 months. The GP management plan examines the patient’s conditions, needs, goals, and other required services, including Allied Health and Specialist visits. Once the plan is in place, it is reviewed every 3-6 months with the CDM Nurse or Aboriginal Health Worker and the GP. The review appointment is a chance to review the patient’s progress compared with their management plan and goals, review associated letters and documents, and consider whether additional services need to be included.
Patients live with one or more chronic conditions every single day but the plan is practice centred not patient focused. The COVID-19 pandemic and restrictions has had a direct impact for many patients with long term conditions and for many preventive appointments such as health assessments and screening activities. This has meant patients need to be even more self-reliant day to day, but we have prepared them for day to day, we have given them a 12 month snapshot. My Care Plan can help practices prepare patients to increase self-management tasks by taking the 12 month snapshot and simplifying into smaller, more manageable tasks and goals.