Abstract No. 2058 (Symposium) : A TOOL FOR GENERAL PRACTITIONERS TO PLAN SERVICES FOR PATIENTS WITH CHRONIC ILLNESS

Conference: 
Author(s): 
Richards B, Ashwell S, Martin C, McNally C ACT Division of General Practice, Deakin, ACT, Australia
Text: 
Introduction:
Australian Governments have proposed trials to determine whether formal coordination of health and social services for patients with chronic illness would result in improved health outcomes and more efficient use of existing resources. The ACT Division of General Practice, an association of general practitioners in Australia' capital city, successfully tendered to conduct a trial, concluding in 1999, in which general practitioners are the care coordinators for their patients.
Methods: The ACT Division of General Practice convened a committee with membership comprising general practitioners, pharmacists, social workers, occupational therapists, community nurses, and community and aged care workers, to develop a clinical tool for general practitioners to undertake a biopsychosocial assessment of their patients, and produce a comprehensive care plan outlining proposed health and community services, for use in this trial.
Results: A Coordinated Care Manual for general practitioners is now being used by 152 general practitioners to produce care plans in partnership with their patients in the ACT Coordinated Care Trial. This presentation outlines the philosophy and process of formal care planning and service coordination afforded by this new clinical tool.
Conclusion:
Through participation in their local association, general practitioners have developed a simple office tool for identifying health issues, determining health and social needs, mapping locally available services to meet those needs, and monitoring the adequacy of the services provided.