Boomerang Project
This page is the homepage of the '
boomerang project', an open source collaborative effort to produce a comprehensive evidence-based 'cycle of care' for patients of Australian general practice, based on the work of participants in the National Primary Care Collaboratives (www.npcc.com.au)
Each patient enrolled in a 'cycle of care' will have a personalised care calendar, outlining the health contacts and activities that they should expect each month for the next 12 months, customised to their health needs.
This collaborative site will develop a suggested 'cycle of care' for a number of chronic disease conditions.
Please feel free to contribute to this project. This page is a 'wiki', which means that it is editable by all collaborators.
It is a work in progress and currently contains lots of gaps and room for comment and improvement.
Contact Tony Lembke c/ tony@lemlink.com.au for edit access.
The page can be edited at
<http://www.writely.com/Doc.aspx?id=ajj5q2mbvrcq_5gg2gfq>
Model of General Practice
The Boomerang Project supports the ‘personal medical home’ model for general practice. This is team based, where patients maintain a strong personal relationship with a particular GP, while receiving integrated primary care from the practice as a whole. Care is evidence based, safe, equitable and accessible. The practice provides a range of services in-house, and acts as a gateway to other services and providers. Integration of care is achieved through a strong relationship between providers, based on shared aims and timely, comprehensive communication. Chronic and preventative care is provided proactively and systematically, and there is a focus on achieving health through lifestyle measures. The practice is centred on the needs of patients, who are acknowledged as the leaders of their own health team, and whose self management skills are fostered.
Chronic Disease Managers
The Boomerang Project is a team based approach to the delivery of proactive, systematic primary care.
We believe that each task should be performed by those most suited to it.
Many practices have benefited from utilising Chronic Disease Managers (CDMs).
The CDM-Admin may have a background in reception / practice management or IT.
They will be responsible for
* maintenance of chronic disease registers
* generating reports of aggregated data
* generating register spreadsheets
* recalls and reminders
* assist CDM - Nursing by proactively recalling patients on registers identified as requiring care or assessment
* ensuring appropriate billing item numbers are utilised
* assisting the CDM - Nursing by arranging appointments / transport for patients where appropriate
The CDM - Nursing will be a practice nurse, and will have clinical contacts with patients.
They will be responsible for
* communicating with patients regarding cycles of care
* patient self management skills
* generating and contributing to care plans
* performing health assessments
* facilitating 'assisted consultations' for the GPs
* coordinating other care providers
Diabetes Cycle of Care
Recruitment The CDM - Admin uses the diabetic register to identify patients who would benefit from a 'cycle of care'.
Criteria would include
* SIPP not claimed
* poor attenders
* high HbA1Cs
* GPMP not claimed
A Disease register / spreadsheet facilitates the identification of appropriate patients.
The patient's usual doctor is given a list of potential patients. The doctor indicates whether they are suitable for the program and any modifications to the routine cycle that would be appropriate for that particular patient.
An invitation to participate in a cycle of care is posted to an identified patient.
Standard Cycle of Care - Diabetes
CDM = Chronic Disease Manager
PN = Practice Nurse
Month
| By
| Code
| Activity
| Item Number
|
0
| CDM (PN) & GP
| CDM 1
| Introduction, Assessment, Plan Preparation
Explain process of cycle of care.
Determine progress towards fulfilling SIPP requirement.
Arrange pathology / assessments required
Prepare GPMP & Prepare TCA.(or review if done previous year)
| 721, 723 or
725, 727
|
0
|
|
| Pathology
|
|
1
| GP
| GP1
| SIPP Review
Review of progress, etc
| 2517
|
2
| Diabetic Educator
|
| Diabetic Education
|
|
3
| PN
|
| Home Health Assessment visit if over 75
|
|
4
| GP
| GP2
| Preventative / Annual Check
Skin, CVS, BP, Breast, Abdo, Prostate, Testes etc
Bowel screening, Cholesterol, MAM etc
| 23 / 36 or
702 if >75
|
4
|
|
| Pathology
|
|
6
| Dietician
|
| Dietician Assessment
|
|
7
|
|
| Pathology
|
|
7
| GP
| GP3
| Care Plan Review
Includes refer for HMR if appropriate
| 725,727
|
9
| Podiatrist
|
| Foot Assessment and Care if required
|
|
10
| Pharmacist
|
| Home Medications Review
|
|
10
|
|
| Pathology
|
|
11
| GP
| GP4
| Finalise Home Medications Review
| 900
|
11
| Physician
|
| Physican / Endocrinologist review if required
|
|
12
| CDM (PN) & GP
|
| Same as CDM1, Month 0.
|
|