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| Domiciliary Health Service Directory (eASi-CD) | Type 2 Diabetes Primary Care and Referral Pathway |
| Practice Nurse Role in CDM |
Overview
Chronic diseases includes diabetes, cardiovascular disease, Chronic Obstructive Airways Disease such as asthma (and certain mental health conditions) . Chronic Disease Management (CDM) in general practice involves appropriate prevention, early identification and best practice management strategies.
MBS Incentives for Chronic Disease Management (CDM)
These incentives include:
- Practice Incentive Payments (PIP) and Service Incentive Payments (SIP) general practice for the early diagnosis and effective management of people with diabetes, early detection of cervical cancer, improved health outcomes for people with asthma.
- Patient rebates for GPs to manage chronic disease by preparing, co-ordinating, reviewing or contributing to CDM plans .
Type 2 Diabetes Primary Care and Referral Pathway
This Care and Referral Pathway is an outcome of the Queensland Health, Connecting Health Care in Communities (CHIC) Type 2 Diabetes Project, which aims to support general practices, within our area, to increase their capacity to manage Type 2 diabetes.
Lifescripts
Lifescripts is a resource kit developed to assist GPs and PNs to do a brief lifestyle assessment and deliver a brief targeted intervention around a problem behaviour, to patients who are motivated to change. Key resources are pads of tear-off assessment sheets and tear-off prescription pads on which individual lifestyle prescrition is documented. SEA-GP can provide your practice with a Lifescripts Resource Kit.
Enhanced Access to Interagencies – Chronic Disease Project (eASi–CD)
The eASi-CD project aims to develop a sustainable model for people with chronic disease who are at risk of avoidable hospital admissions by improving linkages between the GPs, acute care and community services.
The model will enhance access for GPs and hospitals to currently funded community services for people with chronic disease by identifying the eligibility criteria and the referral requirements to the services.
Access to a directory of these services will be through a referral pathway and directory.
The people with a chronic disease and complex needs will be managed by GPs and service providers and the person will be encouraged to attend a suitable ‘Self Management Program’.
Practice Nurse Role in Chronic Disease Management
SEA-GP supports the employment of practice nurses in chronic disease management, and offers help to facilitate a team based approach to chronic disease management through:
Scheduled Practice Visits
- To organize a visit contact Andrea Vancia or phone 07 3390 2466.
Education Events
For workshop dates please see Events page
Resources
Practice Nurse Employee Models - Benefits Summary For a print copy of this booklet developed by the Nursing in General Practice Urban Working Group please contact Vicki McGowan
Case Study for Practice Nurse involvement in Type 2 Diabetes Management This resource was developed by the CHIC Diabetes Project from the Nursing in General Practice Task List Resource.
Nurse Led Clinics - Tip Sheet This was developed by the CHIC Diabetes Project, and is based on the Whitehorse Division of General Practice Resource 'Nurse Led Clinics', 2007.
Nurse Led Clinics – Chronic Disease (Melbourne East GP Network) Revised April 2009.
Also see Nursing in General Practice
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Please refer Info Page