Chronic disease, multimorbidity and GPs’ role in team-based care

Amanda Lyons

2/02/2018 2:24:43 PM

GPs should play a central role on a healthcare team within the system of chronic disease management, Professor Mark Harris, GP and Professor of General Practice at the University of New South Wales told newsGP.

Professor Mark Harris envisions GPs playing a central role in team-based management of chronic disease in the future.
Professor Mark Harris envisions GPs playing a central role in team-based management of chronic disease in the future.

Australians’ increasing life expectancy and changing lifestyle have led to a rise in the prevalence of chronic conditions: about half of all Australians have a chronic disease, while 26% have two or more chronic conditions and 15.8% have three or more, the latter a state known as multimorbidity. All of this has significant implications for the future of general practice.
‘Prevention and management of chronic conditions are not really amenable to episodic-type interventions, and that’s got implications for the funding and organisation of general practice,’ Professor Harris, who has a special interest in chronic disease, told newsGP.
‘The systems and processes that will need to underpin chronic disease prevention and management in general practice include patient-centred communication, self-management, decision-support systems, information systems, multidisciplinary team-work and being engaged with community organisations.’
And the GP will be at the centre of it all.
‘The GP will be kind of like the conductor of the orchestra; you don’t have to be necessarily playing all the instruments,’ he said. ‘But that will vary a little bit and can be tailored to the patients.
‘For example, where a patient has a lot of trouble understanding what needs to happen, such as an elderly patient, the process will require more support, so other providers may need to be brought in.’
Within this type of team-based model, efficient coordination between healthcare providers, patients and other parties, such as family members or Aboriginal healthcare workers, will be vital.
‘What we know about chronic conditions is that fragmentation is the worst thing,’ Professor Harris said. ‘Care that’s disjointed will, at the very least, be inefficient, and we can’t afford to be inefficient.
‘And at the very worst, it will be dangerous and people will get missed or inappropriate care as a result.’
To this end, Professor Harris believes it is vital for the healthcare sector to improve its communication technologies.
‘The real difficulty is not a problem with the software or the hardware, it’s getting things to work across organisational boundaries – enabling the hospital system to talk to the GP system,’ Professor Harris said.
‘Eventually, I guess, we’ll get something like My Health Record really happening. We’re still hopeful, though it’s unfortunately not a reality yet.’
The Federal Government’s Health Care Homes trial indicates some movement towards a team-based funding and organisational model to support management of patients with multimorbidity, although it has faced strident criticism from the medical community, mostly in terms of its funding.
Despite the criticisms, Professor Harris remains supportive of the concepts that underpin Health Care Homes.
‘It’s not rocket science, really,’ he said. ‘Health Care Homes is saying we need teams, we need patient-centred and tailored care, we need information systems, things we were already doing, in lots of ways.’
Professor Harris believes the fundamental shift in chronic disease management in future general practice will ultimately lie in how GPs manage, and think of, their patients.
‘At the moment it’s not the norm that you think, “I really need to be thinking about who is at risk of developing more severe complications”, “Who’s missing out on follow-up appointments?”, or “Who needs some extra support with their self-management?”,’ he said.
‘It’s a different way of thinking: “I’m responsible, not just to individuals, and not just when they see me in the consulting room, but beyond that”.
 ‘That change is difficult, and requires time. And it requires a team and a whole lot of systems and support, not all of which we’ve got properly in place.’
In the latest edition of the Australian Journal of General Practice (AJGP), general practice researchers Julie Gordon, Graeme Miller and Helena Britt ask, ‘What are chronic conditions that contribute to multimorbidity?’, concluding that these may be of a broader range than traditionally considered. The authors also argue that a more conclusive list of chronic diseases would be helpful to GPs, especially if the future of the profession will involve linkage of chronic disease treatment and management to payment structures in general practice, as the Health Care Homes trial indicates.

ajgp chronic-disease health-care-homes multimorbidity

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