AHDGP is pleased to announce its involvement with a consortium that has been appointed to deliver for the Department of Health and Ageing (DoHA) a 3 year pilot of a coordinated care model for diabetes. The consortium, led by global management consultancy McKinsey and Company, was appointed by DoHA following an open tender process.

Bringing together a broad range of expertise from across the primary care, acute care and academic sectors, the consortium is comprised of the following organisations: General Practice Queensland together with selected divisions across Queensland and South Australia; Queensland Health; SA Health; University of South Australia; and Baker IDI. The consortium is also working in close strategic collaboration with Diabetes Australia Queensland, Diabetes Australia, the Health Consumers Alliance SA, and the Queensland Statewide Clinical Network for Diabetes. Finally, the consortium will draw upon an extensive panel of Australian and International experts, including Professor Ruth Colaguiri of the Menzies Institute, and COO of the Kaiser Permanente, Hal Wolf.

Throughout the pilot period, the consortium will work closely with the federally appointed Diabetes Advisory Group, chaired by the Commonwealth Chief Medical Officer with representatives from patient and health consumer groups and key primary health care organisations, including general practice, nursing and allied health.

The pilot itself involves three phases: a 6 month design phase, a 2-year implementation phase and a 6 month evaluation phase. During the design phase, the consortium will work closely with Clinical Reference Groups - made up of General Practitioners, allied health professionals, specialists, patients and carers - to refine the model of care that will be trialled. In accordance with the design elements required by the Department of Health and Ageing, the model will include a component of flexible funding and quality improvement payments as well as voluntary patient registration. Other elements that will be explored during the design phase include the introduction of Care Coordinators, definition and application of care pathways and care packages, enabling IT infrastructure and the role of multi-disciplinary teams.

The trial design will involve both an intervention group of GP practices and a control group, to enable a rigorous evaluation of the outcomes. Selection of participating divisions, Medicare Locals and practices will be based on ensuring that the sample is representative of the overall Australian primary care landscape, with a sample size that is large enough to ensure a robust evaluation. Final decisions relating to the number and nature of divisions, Medicare Locals and practices to be involved in the trial will be agreed by the Department of Health and Ageing on the basis of recommendations from the consortium over the coming months.

The next 6 months will be exciting, as the consortium works with DoHA, the Diabetes Advisory Group, our Clinical Reference Groups and other stakeholders to finalise the design of the coordinated care model that will be piloted for the Government over the following two years. We believe the Coordinated Care for Diabetes pilot provides a unique opportunity to explore innovative ways to further improve the quality of care provided to patients with diabetes, to empower patients and their carers and to support Australian clinicians in delivering the best possible care.

Quality Use of Medicines means:

• Selecting management options wisely
• Choosing suitable medicines if a medicines is considered necessary, and
• Using medicines safely and effectively

The Adelaide Hills Division of General Practice QUM program promotes a range of services and resources to assist practices and patients in the quality use of medicines.

 

 

‘Know your patients, Know their medicines’

 

A Home Medicines Review is a collaborative, patient focused service designed to reduce the risk of medication-related problems.  For GPs it provides comprehensive, up-to-date information about all the medicines, complementary products, devices and other prescriptions being used by patients at home.  For patients it provides education and assistance with medications/ aids/ devices to help people get the best out of their medicines, and avoid medicine-related problems.

 

The Division supports the provision of HMRs for patients by working with practices to develop systems for conducting HMRs, facilitating links with pharmacies and providing consumer education and resources.  Implementation of a practice nurse- led system can be a great way to streamline the provision of HMRs, and provide a proactive, systematic approach to providing this service.

 

Who is eligible for an HMR?

A HMR is available once in each 12 month period, except where there has been a significant change in the patient's condition or medication regimen requiring a new HMR.  HMR is only available for patients living in the community and not for residents of Residential Aged Care Facilities.

 

What are good reasons for a HMR?

·       Currently taking 5 or more regular medications

·       Taking more than 12 doses of medication per day

·        Significant changes made to medication treatment regimen in the last 3 months

·       Medication with a narrow therapeutic index or medications requiring therapeutic monitoring

·        Symptoms suggestive of an adverse drug reaction

·       Sub-optimal response to treatment with medicines

·       Suspected non-compliance or inability to manage medication related therapeutic devices

·       Patients having difficulty managing their own medicines because of literacy or language difficulties, dexterity problems or impaired sight, confusion/dementia or other cognitive difficulties

·       Patients attending a number of different doctors, both general practitioners and specialists

·        Recent discharge from a facility / hospital (in the last 4 weeks)

 

Second (final) consultation

• The patient is recalled to discuss the plan
• Pharmacist and patient are provided with a copy of the plan
• Charge MBS Item 900 after final visit

For assistance in coordinating Home Medicines Reviews, or for resources for your practice and patients, please contact Janette Baker.

 

*These are not strict criteria – a HMR can be done on an annual basis provided there is a clinical need.

 

The HMR Process

First consultation

• Patient is identified for HMR and gives consent
• Generate referral and send to patient’s preferred community pharmacy (patient can deliver form if appropriate)
• Pharmacist conducts home visit and prepares report for GP
• GP and pharmacist discuss report either by phone or email
• The GPs uses the information from the pharmacist report to draft a medication management plan.

A dose administration aid can help to improve health outcomes, improve adherence and reduce adverse events.  Patients who hold either a Gold, White or Orange Repatriation Card may be eligible for a free Dose Administration Aid Service.