Help needed for chronic care

Many general practitioners are keen to adopt a team-based approach that promises better treatment for patients with chronic conditions, but they face a number of significant obstacles, according to research in the School of Commerce at Flinders University, Australia.

If the model is to bring the benefits it promises, government and the Divisions of General Practice will need to provide increased practical and financial support, the research says.

The care model, aimed at patients with ongoing needs related to conditions such as diabetes and asthma, involves GPs, healthcare professionals and allied health services in promoting and monitoring a regime of self-management by patients.

Since chronic conditions are responsible for some 70 per cent of general practice workloads and a growing proportion of hospital admissions, successful programs of self-care have great potential to relieve burdens on the health care system.

While large numbers of GPs have been trained in the model, which was developed by Associate Professor Malcolm Battersby, Director of the Human Behaviour and Health Research Unit at Flinders, take-up rates have been low.

Ms Susan Lambert, a lecturer in commerce, used electronic business models to identify the practical barriers for GPs who want to adopt the self-management model.

She found that introducing a team-based model requires a wholesale shift in the way GPs operate.

"For most GPs it's not a small incremental change; it's a huge change, a paradigm shift in the service delivery," she said.

Ms Lambert said change management was the same for a general practice as for a large company. "Practices which are receptive to change will find it easier than those which have been practising in the same way for 30 or 40 years."

Ms Lambert said that achieving such significant change requires commitment not only from GPs, but from the other stakeholders in the health system, including the government and the divisions of general practice.

For instance, team-based management demands efficient communication, which brings with it the need for improved information technology, Ms Lambert said.

"There is a need to share information, and that is something that GPs have not done very well in the past, for all sorts of good reasons," she said.

"If GPs don't have, or can't manage, the appropriate technology resources, then the team-based approach will just take too much time. More documentation of patients is necessary and the information has to be stored, made available to other people and updated when allied health professionals or specialists are consulted."

Ms Lambert said provision and support of information technology represented a major investment that would require significant funding from government.

Revenue presents yet another problem, since team-based care does not feature in the current models for remuneration: in general, Ms Lambert said, GPs are paid only for face-to-face consultations.

"Currently, if chronic care patients are seen by a practice nurse, the GP does not receive any rebate - either the patient has to be charged or the GP absorbs the costs," she said.

"There is no incentive for GPs: the revenue models have to be adjusted to encourage this kind of care."

Many GPs will also need to alter their own style and attitudes to care. Ms Lambert said GP training is focused on acute care, and most GPs are accustomed to acting independently.

"Dealing with chronic care patients and working in a team require a whole new set of interpersonal skills," she said.

Physical constraints on time and space for consultations may also need to be considered. Out-of-hours appointments are an obvious solution, since visits can be scheduled in advance.

"GPs will need to think outside the normal bounds they are used to. It's not going to happen overnight, and they will need some assistance to achieve it," Ms Lambert said.

"The benefits of the care model are obvious, but introducing it is not an easy thing."

http://www.flinders.edu.au