This opinion piece by David Guest gives his reflections on the recent web based seminar on Care Planning by the Improvement Foundation and his thoughts on the changing nature of chronic disease care in Australia. 


The Improvement Foundation's qiCommunity is continuing its series of webinars on Care Planning. The latest installment followed a previous session by Ros Rolleston, Practice Nurse, from the NSW South Coast. Once again Ros shared her tips and tricks for care planning. Dr Tony Lembke, APCC Clinical Chair, rounded out the one hour session with his 7(+3) CC tips. 

Some suggestions that were well received were: 

  1. Getting the patient's agenda out as the first thing to do in the consultation
  2. Getting the patient to rate their wellness on a scale of 1-10 and asking them how they feel it could be improved
  3. Giving the patient their medication and history list while they are in the waiting room and getting them to update it
  4. Using the same template for all chronic disease patients
  5. Using motivational interviewing techniques for lifestyle changes
  6. Using the patient held medical management folder as a:
    1. communication tool
    2. chore list (viz. homework)
    3. calendar for future visits and follow up

Changing Chronic Disease Management

Chronic disease is an increasing burden in all developed and developing nations. Social and environmental factors will play a more important role in its management than medical investigations and treatment. 

As general practitioners, and advocates for our patients and our communities, we need to adapt our practices and procedures to better manage the changing burden of disease. 

Over a decade ago the American Institute of Medicine, in their Crossing the Quality Chasm report, identified the areas for reform and the barriers to change. Don Berwick, quality improvement guru and founder of the Institute for Healthcare Improvement has briefly defined the elements of what modern disease management will entail. 

Institute of Medicine, Crossing the Quality Chasm

  1. Safety
  2. Effectiveness
  3. Patient Centredness
  4. Timeliness
  5. Efficiency
  6. Equity

Each of these areas has myriad implications for Australian general practice but perhaps patient centredness is the primary issue where local nurses and doctors can have the greatest and most immediate impact. 

There are a hundred thousand things to fix in chronic disease management. Time is of the essence.