Developing a chronic disease management strategy using targeted quality improvement activities

The introduction of MyMedicare, as part of the Australian Government’s primary care reform agenda, includes changes to chronic disease management in general practice.
In conjunction with a quality improvement (QI) driven process to aid patient registration for MyMedicare, practices can undertake a review of their current chronic disease management process and develop a chronic disease management strategy that systemises the ‘who’, ‘how’, ‘when’ and ‘why’, while also considering the ‘what ifs’.
Having robust systems and processes in place aids the maintenance of quality and efficiency, and provides team members with a clear model to follow, through reproducible detailed methods, procedures and routines, which can increase productivity and work satisfaction.
To guide the development of the chronic disease management strategy, practices could focus on a series of targeted QI activities centred around the five components of the Quintuple Aim for Health Care Improvement. The QI activities could cover:

  • practice procedures and processes, e.g. staff orientation
  • recall and reminder processes
  • data cleansing and data quality
  • identifying patients eligible for chronic disease management
  • identifying patients who benefit from multi-disciplinary team case conferences.

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