Chronic Disease Management and the GPPosted by Dr Ged Foley on 13 May 2015
The other day, I saw one of my long-term patients (we’ll call him Fred), a lovely old guy I’ve known and treated for a long time. A few years back Fred developed type 2 diabetes and slowly, with his advancing years, a number of other diagnoses. Of course, along with his diagnoses he’s acquired an increasing number of treating practitioners. As well as me, Fred now sees a Podiatrist, an Ophthalmologist, a Dietician, an Exercise Physiologist, a Cardiologist, an Endocrinologist and a Renal Physician. Each time he comes to see me, Fred brings a large calendar with various days marked off in bright colours denoting appointments with different members of his treating team, cheerfully remarking that he never imagined he’d keep so busy in retirement!
It’s a scenario that we’re all too familiar with and serves to highlight some of the challenges patients face in the event of advancing age and an increasing burden of chronic disease. How do people in this situation stay abreast of their appointments, medication, investigations, exercise and diet programmes and keep informed about their medical conditions? The answer is, they often don’t.
It’s hard enough for those of us who are medically literate to do this, let alone elderly patients who may have early cognitive decline or a lack of education, or both.
Chronic disease now accounts for roughly 80% of the burden of disease in Australia, up to 70% of the adult Australian population can be classified as suffering from a chronic disease and 50% of patients over the age of 65 years are taking five or more medications. Clearly, Fred is not short of company in his current situation.
As doctors and as an organisation, we need to look at the way we co-ordinate the care of our patients with chronic disease. Clearly our aim is to keep patients as well as possible for as long as possible and to avoid unnecessary hospitalisation.
At IPN, we’re currently working on initiatives with various stakeholders in the realm of care co-ordination, developing programmes in partnership with Private Health Insurers and other bodies to improve the outcomes for our patients with chronic disease. The early results, and levels of engagement from doctors and patients, are encouraging, so watch this space!
Fred makes a pretty good job of managing his health right now; in fact, he keeps me on my toes when I’m writing his care plan! Let’s hope there’s a brighter future to those of his peers who are less fortunate.