Ballarat Community Health Centre: Your Partner in CDM
Tanya Gradolf, CDM October 08
Earlier this year, we sent a survey to practices to investigate the relationship between BCHC and general practices. Since then we have been working on ways to improve communication links with BCHC, and more particularly their Health Independence Program (HiP).
How are we improving links between general practices and BCHC?
We discovered through the survey and focus groups that general practices:
- have limited knowledge of the programs offered through BCHC
- do not receive regular/timely feedback from BCHC
- are unaware of the focus on chronic disease management
By meeting regularly with BCHC, we have developed improved systems of communication, including:
- a link placed on the BDDGP CDM webpage for easy access to the BCHC website aimed at improving general practice understanding of BCHC programs & services.
- clarifying information requirements for referrals, and
- developing general practice feedback protocols
How can BCHC assist in care planning?
Access to the following allied health providers and programs:
- Dietitian
- Podiatrist
- Exercise Physiologist
- Physiotherapist
- Diabetes Nurse Educators
- Smoking Cessation
- Health improvement courses
- Counselling services
- Access to the Health Independence Program (HiP)
What is the Health Independence Program (HiP)?
HiP is designed for 'people with chronic diseases with/without complex needs or people with complex needs who may progress towards requiring hospitalisation in the medium to long term' 1.
The focus is on assessment and care planning with a goal of improved self management.
On referral, patients are assessed to ascertain their appropriateness to become involved in HiP.
- Patients who don't meet the criteria are referred to programs/services available through BCHC.
- Patients who are accepted into HiP are allocated a key worker who assesses the patient's requirements and monitors their progress through an 18 month program. The key worker co-ordinates individual wellness plans incorporating a variety of services to meet the patient's.
Practices will receive feedback from BCHC about treatment pathways established for their patients.
Where to now?
We are looking for practices to be involved in a pilot project to determine the effectiveness of the communication systems developed for BDDGP general practices and BCHC.
What is required?
- A willingness to refer to BCHC HiP and other services
- Agreement to follow the specified referral pathways for a 4 month period
- Willingness to feedback to BDDGP on the communication processes during the pilot.
- Agreement to be part of a post-pilot review
How we will support you?
We will provide training on:
- The referral pathways and what is required of you
- Feedback pathways and what to expect
- Provide training to a member of your team (plus $50.00 to assist with wages for individual or relief staff) to be run at BCHC (November 27th AM) with the BCHC staff.
The training includes:
- updates on GPMP and TCA,
- introduction to Health Independence Program,
- patient eligibility,
- assessment and goal setting,
- patient held record,
- services available, and
- Transitioning of patients back to the community.
Being involved in the Pilot Project.
Are you interested? Call Tanya Gradolf at BDDGP (5331 6303) or email .
1. Department of Human Services, Chronic Disease Management Program Guidelines for Primary Care Partnerships and Community Health Services (2006), p15
This article is available online at http://bddgp.org.au/article/2008/10/bchc
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