1. 1 Partnering in Chronic Disease Self Management Sara Drew RN Jo Setter

2. Background CCSM was funded by the Gold Coast Primary Care Partnership Council (PCPC) PCPC recognises that better health and well being can be achieved through working together PCPC comprises gov’t, NGO, local council, communities, general practice

3. Why partnering in self management Benefits of self mgnt well known Address known problems: –Physical access for patients is critical –Courses run in isolation aren’t effective –Outcomes integrated into a holistic health plan –GPs reluctance to refer –Stop/ start nature of courses

4. Chronic Conditions Self Management Trial partnership between GPGC, Spiritus, general practice and Kalwun CCSM to be a part of the patient's health care plan Efficient referral and communication systems Feedback to GPs informing further care planning GPGC utilised the collaborative methodology to learn throughout the trial Partnerships work

5. 5 General Practices 155 referrals 138 patients commenced program 135 completed to date (97.8% retention rate )

6. 100% patients interviewed stated that they have: –Made changes to their behaviour –Attitudes have changed –They feel more in control of their lives, health and wellbeing.

7. Patient with chronic condition identified by General Practice as candidate for General Practice Management Plan GP Referral to Spiritus CCSM program GP Referral to other relevant service Spiritus 6 week facilitated program Feedback to GP Patient Action Plan Letter t o GP outlining commitments and progress CCSM Participants / Spiritus 3 month follow up GP / Patient 6 – 8 month follow up GP / Patient 3 – 5 month follow up Spiritus Notification to GP re enrolment Patient visits GP

8. PartnershipsPartnerships SystemsSystems Leadership & RelationshipsLeadership & Relationships AccessAccess CriticalSuccessFactors

9. Culture Systems Communication CriticalSuccess Factor 1 Partnerships

10. General Practices + GPGC General Practices + Spiritus GPs and front office staff Spiritus + patients Spiritus and other service agencies Patients + GPs WhatPartnerships?

11. GPs and practice staff need to understand the CCSM program courseGPs and practice staff need to understand the CCSM program course 1.What are patients going to learn? 2.How will patients learn it? 3.What is the “language” GPs need to know and understand? Information

12. Referral systems Feedback systems Monthly scheduling CriticalSuccess Factor 2 Systems

13. 80% of participants consulted stated that their doctor’s recommendation was a key factor in participating. The partnership approach helps to “legitimise” the program. Post course follow-up with the GP where action planning, goals and progress is discussed is essential for integrated health management.

14. GP follow-up with patient Spiritus support for participants Trust in the facilitators Relationships in the groups Action Learning over 6 week period CriticalSuccess Factor 3 Leadership&Relationships

15. TransportTransport Accompanying personAccompanying person CriticalSuccess Factor 4 Access

16. What is the perspective of GPs? Dr Sue Gardener Dr Sue Gardener Runaway Bay Doctors Surgery

17. Our front office staff play a key role in recognising the needs of our patients. They know our patients and are often better at identifying suitable candidates for courses. GPs can be too busy or time poor to pick up on the verbal or non-verbal clues from patients Maximises SM moving away from the medical model

18. By giving the front desk ownership of the issue and then follow through by the GP, we found the system worked remarkably well. Significant burden of GP is CD and this helped the practice in supporting, educating, improving care in these pt groups.

19. √T he Partnership approach √ Supportive and professional course delivery model √ GPs and General Practices – new ways of working √ Patients – embracing health & lifestyle change & taking responsibility Conclusion

20. ?Questions 20

21. Thank you Sara Drew sarad@gpgc.com.au Ph: 5507 7777 Mbl: 0448 154 981 21