Chronic Disease Management Programme

10 March 2020

Q. Are there any tips to improve the efficiency of my practice with the new Chronic Disease Management Programme?

A. The Chronic Disease Management Programme is now up and running, and collection of the required data is available through the accredited practice management systems: Socrates, Health One, Helix Practice Manager and Complete GP. The ICGP/IMO roadshows are now over. It is timeto look at the nitty-gritty changes you might consider undertaking to improve the programme's efficiency and your practice's overall financial gains.

This is not a GPIT project; we assisted in the technical specifications meetings, but full credit is due to the ICGP clinical leads for the bulk of the contributions to the programme.Substantial work was undertaken by the IMO and the ICGP clinical leads to ensure that the information gathered is relevant to general practice, and that as much of the information as possible is entered automatically into the returns template from your practice management system,thus minimising extra GP workload. The project has been completed in record time with additional hard work from software vendors, Healthlink and other key stakeholders.The programme's design is intentionally similar to the data returns template. This design offers the user familiarity,with a lot of new intelligent data gathering, which is specific to whichever diseases the patient has. The doctor and nurse returns both use the same template.

Much of the information for the return is populated automatically.For the automatic setting to work, the data must be entered into the correct place on the practice management system. There is no point in free texting clinical findings in a consultation note, as that information cannot be retrieved. Now is an excellent time to remind all staff that when checking height, weight, abdominal circumference and blood pressure, that the information goes into the baseline details section of your software and not as free text.You do not have to change coding practices for your patients. The program will auto-populate the data if the diseases are coded either in ICPC2 or ICD-10. Coding has been a concern for practices that have been coding patients for years with ICPC2. There is no need to change coding systems,and for practices that have not been previously coding,when a data return is sent off the patients will be coded automatically into their system in both ICPC2 and ICD-10.

There is no need to register patients with the PCRS on their GP application suite. When a chronic disease return is sent off, the data return splits into two sections – one goes to the PCRS, which registers and initiates the payment, and the other goes to an HSE data repository where the patient's anonymised data can be processed. For existing patients,you are submitting data on the 'diabetic cycle of care'.

When the new returns are sent from the Chronic Disease Management Programme then payments will be switched to the new model, and the old payments will be turned off.Hopefully at a later stage, a dashboard will be developed to allow you to track returns for your patients. As this is not in place currently, it would be wise to consider a system to check that returns and follow-up returns have been sent and, more importantly, which patients' returns are lagging.

Give some consideration to having a section in this system where new presenting patients can become included.A system to consider for this might be building a database in Excel, where patients and their diseases can be tracked, along with a section for other clinicians to add new patients. The Excel file should be stored on a shared drive on the practice network, with a shortcut to the file available on all clinicians' workstations. Getting this process right can dramatically improve efficiency.

Though much of the data return information can be auto populated,this information can be entered manually into the program, excluding blood results. Please remember to document any medication changes that you have made in the clinical notes as there is no section within the program to enter free text or other clinical information.

Patients over the age of 75 who have a chronic disease are frequent attendees to the practice, with an average of 10 visits per year. You don't have to get bogged down with searching for these patients at the start, as they'll come to you. When they do, ensure the returns go off and they are scheduled for follow-up returns more than four months later. Have a system in place to keep the returns circulating.