Chronic Disease Management during a Pandemic….

Jane Calligeros, Founder and CEO CDM Plus

Practices face many challenges in delivering long term care to patients with chronic conditions during a pandemic.

Australia’s large number of patients with chronic conditions and practices will need to adopt a modified model of care to continue to manage these patients.  In order to minimise preventable hospitalisations and complications, health professionals need to continue to closely monitor the patients that are most at risk.

Many practices are restricting face-to-face consultations due to the risks associated with COVID-19 and have been providing a combination of phone and telehealth consultations.

CDM Plus has teamed up with Precedence Health Care and developed a 3-step process to help practices manage patients with chronic conditions during the coming months.  The process can be modified to suit all practices regardless of size or clinical software.

  1. Identify patients at risk

Before coronavirus Practices would manage patients with chronic disease through a reminder system and booked appointments for Chronic Disease Management such as Care Plans, Reviews and Health Assessments.  Once coronavirus was declared as a pandemic in March, many practices cancelled upcoming face-to-face Chronic Disease Management appointments.

The first step in the process is to identify those patients most at risk. The Risk Stratification Tool (RST) can identify the patients in your clinic that are most at risk of hospitalisation within the next 12 months.

Why do we need to do this step?  Practices have thousands of patients with chronic conditions and it would take weeks to months if we just started with a list that had every patient with a chronic condition. One of the other reasons this step is so important during a pandemic is practices have a limited number of resources and need to allocate these effectively.

  1. Prioritise the type of care using specific care categories

Once you have identified the patients most at risk in your practice you will need to prioritise these patients.  We have called these Care Categories and each patient will need to be assigned a Category (Green, Yellow, Red) by the practice team.

You may wish to do this step with the first part of the management steps when you review the file or base the Care Category selection based on RST score. And remember that these Care Categories can be reassigned at any time.

Depending on which software you use you may wish to document the Care Category “Green”, “Yellow” or “Red” in the patient’s details, appointment notes or warnings within the clinical record.

  1. Manage patients

Once the first two processes are complete, managing patients will become a repeat process for the course of the pandemic.

The management process consists of three steps: Review, Manage and Follow Up.


This is an important step and one you may like to use during the help with the initial prioritisation of patients.  You need to review the clinical record for the patient’s: last visit, recent bloods, observations, immunisations status, allied health and specialist involvement, other provider or programs and upcoming appointments.

With this information review the category assigned and adjust if needed and book the initial appointment.  For example, a patient may be assigned the Green Care Category but when you review the clinical record you may feel that the Care Category may need to be changed to Yellow.

This is a great time to look at your Appointment Types available in your clinical software: decide the icon for each Care Category, amount of time needed for the Nurse/AHW and GP for an initial appointment and follow up appointment.


The management step begins with the initial consultation with the Nurse +/- the GP depending on the Care Category assigned.  We’ve put together a list to check with the patient/carer or family member during the initial consultation and it’s a great idea to have a progress note shortcut for these appointments to make sure you don’t miss something.

There are a list of possible goals and self-management tasks that you can help the patient set and review during the follow up appointments.

Follow Up

This is the last step in the Management process and allows you to review current management and coordinate other activities as needed and each Care Category has a list of prompts.

DOWNLOAD COVID-19 CDM Response Guide

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