Chronic Disease Management (CDM)
Overview
The Division’s Connected: Communicating and Sharing Information to Improve Patient Care Outcomes project aims to improve the long term care of patients with chronic disease by linking patients to a model of improved information flow between general practice, secondary and tertiary care. Facilitation of this long term care requires health and community service providers to work together to plan and provide care that can be shared between the GP and other carers in an accurate and timely fashion. This will be achieved by implementing a model of care for patients that is supported by a shared electronic health record (SEHR).
Objectives
The Brisbane South Division of General Practice ‘Connected’ Program’s objectives are to:
- Integrate and disseminate chronic disease pathways and protocols between general practice and QLD Health
- Recruit practices to the project and orientate practices to the SEHR
- Enhance communication skills within general practice teams to improve patient engagement
- Link the patient engagement strategy to patient self management protocols
- Deliver training throughout the duration of the project. The education will incorporate the expertise of key stakeholders including, but not limited to: QLD Health, Diabetes QLD, Lung foundation, Heart foundation.
Program Details
The Division’s Connected: Communicating and Sharing information to improve Patient Care outcomes program is funded under the Australian Better Health Initiative (ABHI), which was developed by the Council of Australian Government (COAG) to focus on preventing and reducing the burden of chronic disease. The ABHI initiative has 5 key focus areas, the fifth area is Improving the communication and coordination between care services throughout Primary Care Integration, which is the vision of this program.
BSDGP will be assisted by GP partners in the implementation of this program by integrating the shared electronic health records (SEHR) system. The ‘Connected’ program will focus on utilising the existing technology of SEHR, which will be introduced into the management system of chronic diseases, and will facilitate improved communication between clinician, patient and their team care providers over the next 3 years. All patients within general practice in the Division with chronic and complex diseases (diabetes, cardiovascular related disease and chronic respiratory disease) will have the opportunity to be linked to a SEHR. The strategy that will be used to ensure uptake in general practice will be the Collaboratives methodology.
Resources
Links
Contact Us
Debbie Croyden
Business Systems Coordinator
Email: dcroyden@bsdgp.com.au
Phone: 07 3274 1886
Rebecca Dunn
Program Manager
Email: rdunn@bsdgp.com.au
Phone: 07 3274 1886
Jacqui Hawgood
Program Manager
Email: jhawgood@bsdgp.com.au
Phone: 07 3274 1886