1. C reating D e……… M omentum - the Gippsland experience of implementing a Chronic Care Model

2. The Chronic Care Model Taken from the Institute of Health Care Improvement website www.ihi.orgwww.ihi.org

3. Anticipated Outcomes of the project Development/strengthening of multidisciplinary teams More efficient and effective patient care due to streamlined processes Defined roles for team members Common risk assessment Staff training opportunities Engagement of patients

4. Case Study - Foster - the first 3 months Case Study - Foster - the first 3 months GAP analysis – current practice V’s CCM KPMG evaluation Patient survey – around group education program Reference group- project worker, GPs, diabetic educator, practice nurse, dietitian, health promotion officer & others

5. Case Study - Foster - developments so far IT- Data cleansing, coding, recall systems IT- EPC item numbers (721,723,DSIP) and referrals Employment of diabetic educator (care coordinator role) Practice nurse role in foot assessments (vascular Doppler) Chronic condition self management course (Flinders Model) Patient Kept Record Community Education- “PALS”

6. Foster – outcomes to date Patient survey – involvement in process IT systems to monitor outcomes Internal systems review Agreed roles and responsibilities Agreed pathway to follow Self management support Community linkages – group education, PALS Practice nurse role expansion

7. Learning’s to Date - Benefits Multi-skill, multi-agency approach Resource development Use of patient held record Care planning Role delineation Training opportunities Improved internal service delivery Improved communication

8. Learning’s to date - Barriers ResourcesIT Staff turnover Role delineation – silos Relationship management Readiness for & rate of change Competing priorities Lack of co-ordination of projects

9. Key Learning’s so far Public Vs Private providers Need to have realistic expectation of what is achievable Time commitment required Need for someone to drive implementation of the chronic care model

10. The next step…. Looking to roll out more broadly to other agencies Working on an implementation kit How do we engage other agencies/programs (HARP)/projects? How can agencies work together to improve service delivery? What else may be involved?