Saturday, July 31, 2010

Chronic Illness

Supporting general practice to provide optimal care and contribute to the achievement of the best possible health outcomes for patients with a diagnosed chronic illness, the Chronic Illness team aims to:

• Develop a better informed public, particularly in regard to illness and injury prevention together with self management and maintenance of their care. • More efficient use of practice resources.

What’s On Offer?

Group diabetes education program (English)
• Two programs per month located in Nunawading and Box Hill. Each program consists of 3 three hour sessions over 3 weeks.
• One program located in Hawthorn consists of a 5 half day sessions over 5 weeks.
• Facilitators: diabetes educator, dietician, podiatrist and community nurse.
• Referral to the GP Network is by telephone or through the Victorian Statewide Referral Form (VSRF).

Group diabetes education program (Mandarin and Cantonese)
• Each program consists of 3 half day sessions over 3 weeks. Facilitators; Chinese speaking diabetes educator, dietician and GP.
• Referral to Whitehorse Community Health Service

Limited one on one education
• Mainly for patients commencing insulin.
• Referral on request to the GP Network

Diabetes and asthma management and resources
• Up to date information is available on all aspects of diabetes or asthma to GPs through clinic visits, professional development sessions or mail outs.
• Practice clinical data analysis and feedback against asthma and/or diabetes management guidelines
• Promotion of asthma action plans
• Support for identification of the needs of patients with asthma, including smoking status recording.

Practice visits
• Recall and review systems
• MBS advice including claiming the Diabetes SIP and enhanced primary care items such as GP management plans and referral for team care arrangements.

Collaboration
• Supporting collaboration with other health providers such as the ‘Improving the Journey’ diabetes management program
• Working with Primary Care Partnerships, Community Health Services and Eastern Health Hospitals to improve communication and shared care.
Asthma and diabetes clinics
• Provided by GPSS: Contact the GPSS Team Leader

Diabetes Prevention
• Lifestyle Modification Programs are available for patients aged 40+ years who are at high risk of developing diabetes. • Patients who score 15+ on the Australian Diabetes Risk Tool are eligible to attend these 5 week programs which are free for people on low and medium incomes.

• Referrals can be made directly to the GP Network to assist practices in finding suitable programs for patients. The Australian Diabetes Risk Tool and the referral forms are available in paper and electronic forms on www.megpn.com.au

Resources at your fingertips for the EPC items:
The GP Network has developed a range of resources including:
• “How to” instructions for GPMP and TCAs
• Templates that can be loaded onto Medical Director and other medical software
• Letter of engagement
• Letter of review
• Medicare allied health services