Chronic Disease Management (CDM)

The ‘Health Assesments and Chronic Disease Management – finding your way through the maze’ resource is a flowchart that contains many chronic disease management and health assessment resources and templates.

This flowchart guides GPs and practice nurses through the complexity of Medicare item numbers.

Behind each box, there is information only or the Medicare item and descriptor, documents, templates, and website links relevant to the specific item number or numbers that have been clicked.

The flowchart can be accessed directly through www.mbgpn.com.au/cdmflowchart. A print version of this flowchart is also available when you click on the link.

The flowchart will always be a ‘work-in-progress’ given that new templates and documents are continually being developed. Occasionally even new item numbers become available.

Your feedback and suggestions are encouraged so that we can continue to update and refine this flowchart and make it an accurate and valuable resource.

For any comments, please contact barbara@mbgpn.com.au.

Self Management of Chronic Disease

Currently, Australia has an ageing population with an associated rise in the incidence of chronic disease. (AIHW 2006; DoHA 2006; AGPN 2006) These factors attribute to approximately 80% of the total burden of disease in Australia incurring significant social and financial costs to the community, and about two thirds of avoidable hospitalisations. (NHPAC 2006; PHIDU 2007)

This is justification enough for the Federal Government to correlate many Primary Health Care Initiatives around chronic conditions, their prevention and management. Some of these include: The Australian Better Health Initiative (ABHI); the Re-Energize program; and the Collaboratives program. By targeting this area Australia can achieve a cost effective improvement in the health status of the population.

Many of these initiatives are delivered via GPs as general practice is a fundamental element of the primary health care system in Australia. The Moreton Bay General Practice Network's role is to support GPs by developing tools and resources to assist general practices to deliver better patient outcomes in the ever expanding area of chronic disease prevention and management. The MBGPN aims to continuously evolve to address these gaps and integrate new strategies into the current model of care in general practice.

For specific details on MBGPN's activities targeting chronic disease management and prevention check out the documents for download below.