PGPN will support general practice through the delivery of a practice enhancement program which aims to support improved systems and workforce development to improve care coordination of patients presenting with chronic disease and conditions.
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Coordinated Veterans' Care Ailsa Gregory is available to support practices with information regarding this program. Ailsa can be contacted via email or by telephone 9708 8019.. |
PGPN will disseminate information and resources promoting a whole of practice approach to coordination of chronic disease management and care, this will include:
| • | Promotion and training of the Clinical Audit Tool and/or database manipulations to identify the relevant practice population cohort and establish condition registers |
| • | The development or utilisation of available clinical templates and processes to establish electronic systems of practice |
| • | Presentation of the business case for the delivery chronic disease management services using a recall and reminder system for patient follow up, following the completion of a PHA |
| • | Promote and support the role of the practice nurse in coordinating the delivery of chronic disease management and care |
| • | Promotion of register, recall & reminder systems through practice manager and practice nurse networks and practice visits. |
| • | Link the utilisation of register, recall and reminder systems with broader preventative health and chronic disease programs and specific topics, including diabetes, CVD, cancer and respiratory |
PGPN will assist general practice with access to current information on relevant MBS item numbers available for utilisation to support care coordination of patients with chronic conditions and build business capacity
PGPN will be initiating a new primary care integration project in 2011-12 which aims to support and facilitate improved communication and the patient journey between general practice and local community health services and programs across the Frankston and Mornington Peninsula region. The project will focus on increasing the utilisation of the Victorian Statewide Referral Tool (VSRF), e-referral and communication together with a standardized service provider feedback mechanism and template when communicating with GPs.
