Chronic Disease Management

About

The South Australian Chronic Disease Action Plan recognises that chronic diseases are among the most prevalent, costly, and preventable of all health problems.  Around 46% of South Australians have been diagnosed with at least one chronic disease and an estimated 15% of South Australians suffer two or more chronic diseases.

The Commonwealth Government has identified eight National Health Priority areas, which contribute significantly to the burden of illness and injury, and have potential for health gains and reduction in the burden of disease.    

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How we can help

gpns is committed to supporting and assisting the general practice team in the management of patients with chronic disease and provides the following services:

• clinical tools to assist in the detection and management of chronic diseases.  
• clinical updates.  
• information about the Medicare Benefits Schedule including the Primary Care items, the Chronic Disease Management Items and help with claiming rules and waiting periods for CDM items.     
• information and requirements for claiming the Practice Incentive (PIP) and Service Incentive (SIP) Payments including the diabetes and asthma cycles of care.   
• help to develop systems to support the management of patients with chronic diseases.  
• help to identify opportunities where greater use of chronic disease item numbers could be beneficial to practices through the business case spreadsheet.  
• information about local providers and services including chronic disease self management services and the Chronic Disease Community Program.   
• Nursing Support: Specific in house support is available to assist practice nurses (particularly those nurses new to general practice) to develop a more systematic approach to chronic disease management using recall and reminder systems, billing, GPMP/TCAs and data extraction. For more information or to book a practice visit, please contact gpns GP Plus Nurse Systems Support, Carol Buchanan.     

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