Precedence Health Care’s Chronic Disease Management Service (CDMS) is a web-based productivity tool for GPs, care providers and patients to assist them to better manage chronic disease.
Diabetes WA has received funding from the Department of Health and Ageing to assist with the implementation of the service in the Perth metropolitan area.
This funding has also enabled enhancements to be made to the service to make it more “consumer friendly” and to better address self-management principles.
CDMS aims to tackle the major issues that confront most GPs and practice nurses when trying to manage their chronically ill patients using MBS Chronic Disease Management (CDM) Items. These issues include:
- Not enough time to meet requirements, particularly meaningful collaboration with the care team and regular documented review of patients;
- Too much administrative and bureaucratic overhead;
- Difficulty of compliance and risk of audit; and
- Rebates not sufficiently rewarding of good practice.
CDMS currently covers all major chronic diseases, including diabetes, coronary heart disease, chronic heart failure, stroke, chronic kidney disease, osteoarthritis, asthma and chronic lung disease. It also manages depression as a co-morbidity with other chronic diseases.
CDMS has been trialled in WA and Victoria and now has over 800 care plans generated using the service. Preliminary evaluation shows CDMS has been successful in increasing the use of care plans by 60%, improving team collaboration by 140%, and improving care plan follow-up and review by five to ten-fold.
These improvements were obtained without any increase in GP or practice nurse resources. Overall, GP and practice nurse productivity was multiplied by a factor of over 250%. CDMS achieves these benefits by:
- Automatically creating a shared electronic health record for the patient from the clinical desktop (e.g., MD3);
- Creating best-practice, individualised GP Management Plans (GPMPs) and Team Care Arrangements (TCAs) within seconds, including plans for patients with multiple comorbidities;
- Managing the entire TCA process automatically (including distribution of the TCA, auditable two-way communication with the care team, and electronic signing and distribution of all documentation for Allied Health and Home Medication Reviews);
- Continuously tracking progress of the tasks in the GPMP and TCA, so that GPMP and TCA Reviews as well as Annual Cycles of Care can be easily completed at any patient visit without wasting time.
CDMS facilitates collaboration among the care team and with the GP. It achieves this by allowing the Allied Health team to:
- Communicate with the GP about the care plan through the website, via e-mail, or VOIP
- View, print, or save all documents including the TCA and electronically signed Allied Health Referral forms and Home Medication Review Referral.
- Record appointments made, attended or missed
- Add progress notes and remarks for the GP, care team and the patient
- Upload documents to share with the GP, care team, and patient.
CDMS encourages patient compliance with the care plan by sending reminders by email or SMS of upcoming appointments with the GP and the care team.
The system will also create a one-page summary of the care plan for the patient which outlines all the self-management goals, tasks and appointments which need to be made for the duration of the care plan.
CDMS is a web-based service and requires no installation. It is quick to learn and easy to use. It is currently compatible with MD2, MD3, Best Practice, and Argus e-referral software.
If you would like more information on CDMS or would like to see a demonstration, please contact Gerry Doyle at Diabetes WA on geraldine.doyle@diabeteswa.com.au or phone (08) 9436 6243.