5 Key Fundamentals of a Successful Chronic Disease Management Program
- Chronic Disease Management, Cubiko
- Chris Smeed
- February 3, 2023
Chronic Disease Management (CDM) is a vital aspect of healthcare that aims to improve the health and well-being of patients with chronic conditions. It involves a coordinated and comprehensive approach to managing the health of these patients, which includes regular check-ups, screenings, and treatments.
To ensure the success of a CDM program within a practice, it is essential to have a structured process in place that focus’ on the key fundamentals. These fundamentals include:
- access and support to funding,
- a structured process,
- clinical care,
- the utilisation and capacity of your team, and
- involving the team
In this blog post, we will outline and discuss the 5 key fundamentals that are essential when running a successful CDM program.
1. Access and support to funding
The first key fundamental of a successful CDM program is having access and support to funding. Having access to funding and financial support is crucial for the sustainability of a CDM program within a practice. This funding can help to provide more access to subsidised services for patients, which in turn leads to an increase in clinical care within the practice. This can include covering the cost of medications, equipment, and visits to specialists.
Furthermore, the funding can be used to hire additional staff, such as nurses and care coordinators, to support your CDM program. This added support can help to improve the overall health of patients with chronic conditions and increase the efficiency of the practice. Additionally, the funding can also be used to invest in technological solutions, such as telehealth, that can help to improve the quality and accessibility of care provided for patients with chronic conditions.
2. Structured Process
The second key fundamental of a successful CDM program is having a structured process in place. A structured process is necessary to manage the conditions of patients with chronic diseases. This includes:
- Setting goals and tracking your progress,
- Identifying patients in your practice who may be eligible for services, and
- Ensuring that appointments are available for patients when asking them to book in with our practitioners or nurses
To achieve this, you can use tools such as Cubiko, electronic health records and patient management systems to help identify patients who may be eligible for services and subsequently schedule appointments for these patients.
By implementing a structured process, you can ensure that patients receive the care they need in a timely and efficient manner. Additionally, a structured process can also help to improve the accuracy of data and record-keeping within the practice, which can be used to your track progress and identify any areas for improvement for your practice.
3. Clinical care
The third key fundamental of a successful CDM program is a focus on the clinical care provided. Focusing on clinical care is essential for the long-term health of patients with chronic conditions. By providing more access to subsidised services, practices can improve the health of their patients and decrease the risk of long-term health issues. This can include regular check-ups, screenings, and treatments, as well as education on self-management of their condition.
Additionally, you can use care teams, such as nurses and care coordinators, to provide support and education to patients about their chronic conditions. This helps to improve patient outcomes and in the long term reduce hospitalisation rates. By prioritising clinical care, you can improve the overall health of patients with chronic conditions, leading to better patient outcomes and reduced healthcare costs.
4. Utilisation and capacity
The fourth key fundamental of a successful CDM program is reviewing the practice’s utilisation and capacity. Before ramping up a CDM program, it is crucial to review your practice’s utilisation and capacity. The last thing you want is to spend valuable time identifying patients who may be eligible for services and trying to book them in for an appointment, come to find that you actually have no appointments availability at the moment.
By reviewing your practice’s utilisation and capacity, you can ensure that you have the necessary resources and staff to support your CDM program. This can include identifying available appointment times, hiring additional staff and making sure that they have the necessary equipment and technology to support the program.
Additionally, these insights can aid you in identifying areas where you grow or improve in the future to better serve your patients.
5. Involving the team
The fifth and final key fundamental of a successful CDM program is involving your team. Involving your team in the CDM program is vital for its success.
This includes providing them with the necessary tools and resources to support patients with chronic conditions, as well as providing training and education on how they can use these tools effectively.
Furthermore, the benefit of involving the team can help to improve the overall coordination and communication within the practice. The team can work together to identify patients who may be eligible for services, schedule appointments and provide support and education to patients.
By getting your team involved, you can ensure that everyone is working together towards the common goal of improving the health of patients with chronic conditions. While also helping to create a sense of ownership and engagement among staff, which inturn can improve the overall culture of the practice and lead to better patient outcomes.
In summary, implementing these key fundamentals can help practices provide better care to patients with chronic conditions, reduce healthcare costs, and increase the efficiency in your practice. By following these guidelines, you can ensure that your practice provides the best possible care to patients with chronic conditions.
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