Jane Calligeros, Founder and CEO CDM Plus

My Care Plan is a patient resource that can help GPs and Health Professionals to empower patients to self-manage their chronic condition, so they can stay well and out of hospital.  A chronic condition is often life long and includes 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, monitoring observations and symptoms and as health professionals we can help increase patient skills and implement self-management strategies.  When patients present unwell to primary care or hospital they are triaged into a category based on their presenting problem, observations and symptoms.  My Care Plan includes an escalation protocol or ‘patient triage’ that can help patients and their families or carers recognise when they need to seek help.

My Care Plan

has simplified patient self-management into 4 sections:

1.     Learning about My Conditions can help me self-manage – By helping patients 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 awareness and help patients self-manage.
3.     I know when to Contact My GP if I’m feeling unwell – Recognising when they are unwell is a really important part of self-management.  If a patient can recognise 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 hospital if I’m feeling very unwell – Hospitalisations are a burden on our health system and many of the common presentations are due to 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 and almost half of Australians have one or more of the chronic conditions (Australian Institute of Health and Welfare, Web Report, 13th May 2021). Chronic disease management can be overwhelming for health professionals, patients, and their families.  Chronic conditions place a large burden on the resources in primary care and many general practices do not have the resources to manage the increasing number of patients.  Self-Management can take some time, and My Care Plan can help patients take smaller steps to increase confidence while maintaining regular reviews with GPs and Health Professionals. 

In primary care, chronic disease management 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 for the next 12 months.  The plan looks at the patient conditions, patient needs, goals and other services that may be required including any 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 progress against the management plan, goals and review any documents from the whether any other 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.