This document discusses chronic disease management (CDM) in general practice. It considers what common chronic diseases should be formally managed, such as diabetes, asthma, COPD, and hypertension. It then discusses CDM payments and criteria for claiming them. Various ways of organizing CDM are proposed, including opportunistic care, dedicated clinics, nurse-led clinics, disease registers, protocols, and guidelines. Both the polyclinic and generalist models of care are examined along with their advantages and disadvantages. Creating and maintaining accurate disease registers, protocols, and patient records are also discussed, as well as the role and value of auditing chronic disease management.
This document discusses chronic disease management (CDM) in general practice. It considers what common chronic diseases should be formally managed, such as diabetes, asthma, COPD, and hypertension. It then discusses CDM payments and criteria for claiming them. Various ways of organizing CDM are proposed, including opportunistic care, dedicated clinics, nurse-led clinics, disease registers, protocols, and guidelines. Both the polyclinic and generalist models of care are examined along with their advantages and disadvantages. Creating and maintaining accurate disease registers, protocols, and patient records are also discussed, as well as the role and value of auditing chronic disease management.
This document discusses chronic disease management (CDM) in general practice. It considers what common chronic diseases should be formally managed, such as diabetes, asthma, COPD, and hypertension. It then discusses CDM payments and criteria for claiming them. Various ways of organizing CDM are proposed, including opportunistic care, dedicated clinics, nurse-led clinics, disease registers, protocols, and guidelines. Both the polyclinic and generalist models of care are examined along with their advantages and disadvantages. Creating and maintaining accurate disease registers, protocols, and patient records are also discussed, as well as the role and value of auditing chronic disease management.
Dr Bruce Davies Scope What common diseases? Should they be formally managed? Frequency Importance Follow up affects outcome Know what to do Where is follow-up most appropriate? Brainstorm What conditions are important under these criteria? Perhaps Diabetes Asthma COPD Hypertension ? Epilepsy High risk drug users ie DMARDs etc Contraception CDM Payments Asthma Diabetes Small fee per GP per year Criteria to claim Requirement for audit Ways and Means Opportunistic Dedicated clinics Nurse led clinics Specific appointments Disease registers Protocols Guidelines Better Care or Just PC Sometimes hard to tell! Evidence for effectiveness? Need for audit More work More treatment More iatrogenic problems? Polyclinic Model of Care The list of things can grow and grow. Advantages. Disadvantages. Professional satisfaction. Quality. Fragmentation. Fall between two stools. Generalist Model Copes with everything. Advantages. Disadvantages. Professional satisfaction. Holistic. Failure to care systematically. Registers Creation. Maintenance. Accuracy. Usage. Whose responsible? Manual viz. Computer. Protocols Authority. Ownership. Access. Who follows. Benefits. Disadvantages. GOBSAT viz. EBM. Records Whose responsible? Paper or computer? Accuracy. Meaning. Why poor? Audit PC or use? Who does? More work for what value? Do people change as a result?