Jane Calligeros, Founder and CEO CDM Plus

Chronic Disease Management is all about the Review!  That’s right.  You heard it here first.  It’s all about the Care Plan Review.  We can prepare the most detailed Care Plan with a patient that has a chronic condition, outlining goals, treatments and services for the next 12 months but a Care Plan by itself is not Chronic Disease Management.  Chronic Disease Management is all about long term care for patients and by reviewing the patient at regular planned intervals we can monitor and prevent disease complications.

At CDM Plus our purpose is to better manage patients with chronic disease and promote activities that can help prevent and detect chronic disease.  We understand Chronic Disease Management can be overwhelming, especially if you are new to the role, or have limited resources. We do this by providing the practice team with training and the resources to implement long term care for patients with chronic disease.  We have a set of systems and processes that makes Chronic Disease Management easy.

Let’s look at the Top 3 Chronic Disease Management Activities:

  1. Care Plans: The statistics tell us that 1 in 2 patients have a chronic condition, so technically 50% of your patient population should have a Care Plan in place. For example, a practice has 5,000 active patients (which means 1 in 2 patients have a chronic condition), so 2,500 patients should have a Care Plan.  How many active patients does your practice have?  How many Care plans did your practice complete in the last 12 months?  Now, you can use secondary software, or disease registers to get a more accurate number of active patients with a chronic condition that require a Care Plan.
  2. Care Plan Reviews: Most practices are great at getting a patient into the clinic and preparing the patient Care Plan for the next 12 months.  Then what happens is the patient does not come back for 12 months until they are due for the next Care Plan!  I’ll say it again.  Chronic Disease Management is all about the review! A Care Plan no matter how brilliant is useless if we don’t look at it and measure the outcomes.  Each Care Plan should at least be reviewed at least once in a 12 month period and more frequently for patients with multiple chronic conditions.  Now let’s go back to your numbers.  If our active population is 5,000 and 2,500 patients have a chronic condition requiring a Care Plan, then as a minimum we should be completing 2,500 Care Plan Reviews in a 12 month period.  As a minimum.  So….how many Care Plan Reviews did your practice complete in the last 12 months?
  3. Health Assessments: Health Assessments are considered a Chronic Disease Management activity even though they are technically a prevention activity.  Some patients will have an existing chronic condition and also fall into a category that makes them eligible for a Health Assessment, but other patients may not have any conditions.  The goal of the Health Assessment is to identify risk factors and early prevention and detection activities.  Hands up if you can tell me how many different types of Health Assessment categories there are currently available in Primary Health Care under the MBS?    Yup that’s right.  Eleven different types of Health Assessments!!!  How many of these is your practice doing?  Most practices end up doing only one or two target groups because the number of patients is greater than the number of resources available.

I just made Chronic Disease Management a lot harder, didn’t I?  No.  I just gave you the magic formula for your Chronic Disease Management target number. Let’s just look at the number of appointments you would need for the Nurse/AHW a day to manage the patients with chronic conditions, which would be the number of Care Plan and Care Plan Review appointments you would need over the next 12 months.  From our example, I would need 5,000 Chronic Disease Management appointments (2,500 Care Plan appointments and 2,500 Care Plan Review appointments).  If a clinic operates Monday to Friday and let’s say 48 weeks a year to allow for Public Holidays an Annual Leave, you would need 20 Chronic Disease appointments a day.  How many Chronic Disease Management appointments does your clinic average a day?

Do you want to know how you to reach these targets?  The easiest way is to become tactical in the approach and delivery.  We have lots of resources available for practices that will help support your team.