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Chronic Disease Management

Chronic Disease Management. Beyond QoF Payments Dr Bruce Davies. Scope. What common diseases? Should they be formally managed? Frequency Importance Follow up affects outcome Know what to do Where is follow-up most appropriate?. Brainstorm.

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Chronic Disease Management

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  1. Chronic Disease Management Beyond QoF Payments Dr Bruce Davies

  2. Scope • What common diseases? • Should they be formally managed? • Frequency • Importance • Follow up affects outcome • Know what to do • Where is follow-up most appropriate?

  3. Brainstorm • What conditions are important under these criteria?

  4. Perhaps • Diabetes • Asthma • COPD • Hypertension • ? Epilepsy • High risk drug users ie DMARDs etc • Contraception

  5. CDM Payments • Asthma • Diabetes • Small fee per GP per year • Criteria to claim • Requirement for audit

  6. Ways and Means • Opportunistic • Dedicated clinics • Nurse led clinics • Specific appointments • Disease registers • Protocols • Guidelines

  7. Better Care or Just PC • Sometimes hard to tell! • Evidence for effectiveness? • Need for audit • More work • More treatment • More iatrogenic problems?

  8. Polyclinic Model of Care • The list of things can grow and grow. • Advantages. • Disadvantages. • Professional satisfaction. • Quality. • Fragmentation. • Fall between two stools.

  9. Generalist Model • Copes with everything. • Advantages. • Disadvantages. • Professional satisfaction. • Holistic. • Failure to care systematically.

  10. Registers • Creation. • Maintenance. • Accuracy. • Usage. • Whose responsible? • Manual viz. Computer.

  11. Protocols • Authority. • Ownership. • Access. • Who follows. • Benefits. • Disadvantages. • GOBSAT viz. EBM.

  12. Records • Whose responsible? • Paper or computer? • Accuracy. • Meaning. • Why poor?

  13. Audit • PC or use? • Who does? • More work for what value? • Do people change as a result?

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