Changing Systems to Support Chronic Condition Management:   Developing Registers in General Practice

The following piece was written by Ms Annie McCaughey, a primary health care worker within the Divisions of General Practice in Tasmania. We think it provides a good example of how workers in the field really can make change in their practice systems to meet the growing demands created by chronic conditions. Annie is currently completing her Graduate Certificate in Health (Self-Management) at Flinders University.



Changing Systems to Support Chronic Condition Management:  Developing Registers in General Practice

This piece describes and demonstrates an organizational change process undertaken recently by our service that supports Chronic Condition Management by applying evidence-based knowledge, collaborating at a macro, meso and micro level.

To influence organisational support and delivery system design changes, the creation of an efficient diabetes register and recall/ reminder system in two local general practices that supports chronic condition management was the over arching aim. In order to achieve this, chronic conditions teams were formed. The implementation of a diabetes register/recall/reminder system, by the team, was hoped to provide essential data on the size of the diabetic population in practices and to inform the Department of Health on public policy. There was a sizeable amount of data to be collected, given our understanding that 70% of general practitioner visits are for chronic conditions. Evaluation of the project was measured by the number of diabetes patients entered on the register, the effectiveness (ability to send out recall letters to patients on the register) of the recall/ reminder systems to positively affect patient safety, its benefits to chronic conditions management, the number of patients on an Annual Cycle of Care and practice team satisfaction.

In 2001-02 The Australian Government introduced the National Integrated Diabetes Program. This initiative aimed to improve prevention, more effectively diagnosis early, and promote better management of diabetes in general practice through the introduction of funding and support for systematic care, based on 12 key clinical indicators performed as an annual cycle of care. A major part of promoting such an approach is the use of a disease register and regular recall and review system, along with greater involvement of practice nurses and a system for auditing standards of care. This also includes intensive follow-up, and use of clinical management guidelines integrated with self management support systems (Georgiou, Burns, Penn, Infante, Harris, 2004).

‘Improving clinical outcomes either for the individual patient with a chronic health problem (chronic disease management) or for a population of patients (practice improvement) requires a multifaceted approach. Chronic Condition Management (CCM) is designed as an organizing framework for improving chronic illness care, and is an excellent tool for improving care at both the individual and population level,’ (Fiandt, 2006). Achieving this outcome was the aim of the team. ‘The CCM consists of six distinct concepts identified as modifiable components of healthcare delivery: organizational support, clinical information systems, delivery system design, decision support, self-management support and community resources. While the first four concepts in the CCM address practice strategies, the final two are specifically patient-centred. Chronic disease management or practice improvement can be based on each of these concepts separately, or on the model as a whole. When the concepts are used separately, it is essential that the clinician keep in mind the other components of the model’ (Fiandt, 2006).

First Steps
The understanding and implementation of organizational support, delivery system design and decision support will, theoretically, represent a multifaceted approach that can evolve to support self management, and involve the engagement with community resources such as community lifestyle programs akin to Heartmoves, walking clubs, community gardens and ‘Active city park’ here in Launceston. My initial step was to assess the needs and willingness to embrace change within a number of practices, and to then determine what we need in order to accomplish a process to effect change. Two practices meeting these criteria have been selected to take part in the pilot program and their problems and barriers to effecting change have been discussed and documented:

The following outlines the aforementioned issues:

  • The culture of the practices has been that of providers of reactive, rather than planned care. This often meant the patient’s chronic disease being of secondary importance and requiring a later appointment;
  • Insufficient time during busy working days to construct a register;
  • Lack of understanding of the significance/importance of a register;
  • Inconsistent methods of recording disease by GPs resulting in patients not going on the disease register at all;
  • Reactive rather than planned care often meant the patient’s chronic condition being of secondary importance and requiring a later appointment;
  • Resistance to change; and

The attitude of ‘Why recall when there are no available appointments, this just falsely raises expectations and leads to more frustration for everyone?’

According to the Theory of Change Management, ‘bringing about change is difficult. Sound reasons for change do not automatically translate into change in behaviour or practice. The advent of evidence-based medicine, in particular, the production of best practice clinical guidelines, has been a significant recent advance in medical science. Current studies show that 30 to 40% of patients do not receive care, while approximately 20 % of the care provided is not needed or is potentially harmful’ (Wade, 2006). National Health and Medical Research Council (NHMRC) evidence-based guidelines and the goals for optimum clinical management of diabetes are published and reviewed yearly to encourage their use by GPs and address this appalling gap. ‘The yearly review is a time for more detailed assessment, updating the problem priority list and the re-establishment of goals, and contractual arrangements for management. Eating plan, lifestyle, home monitoring and treatment need to be reviewed. There needs to be a full system review checking for vascular, renal, eye, nerve and podiatric problems. As there is an increasing trend towards involving specialist allied health professionals, the yearly visit is a good opportunity to coordinate follow up’ (Harris, Mann, Marshall, Phillips, Webster, 2008).

To fully utilize these evidence-based guidelines and to achieve an annual complications screening and review, a reliable register/reminder/recall system is important and needs to be put in place. Even with the best of intentions, the absence of a management plan translates to suboptimal care for most chronic conditions patients, as is indicated by Funnell (2003) whose research found that, ‘The gains from short-term programs without follow-up were generally lost by 6 months. This finding points out the need to provide ongoing education and support for self management as part of continuing care.’

The Impetus for Change
Both practices in our change initiative agreed to be part of a change management process, as they had now identified basic problems in identifying every chronic condition/s patient, and had no policy in place to rectify and contain this ever-growing problem. Further questioning revealed that they assumed that most of their diabetes patients received best practice care, ie on an Annual Cycle of Care, but they had no way of proving this assum26 February, 2009t the first practice and correlating the patients in the register (53) with those on diabetes medication (253) revealed a vast discrepancy. A similar problem was found in the second practice. Both practices recognized the need for a register/reminder/recall system as theirs was at best ad hoc and reactive and consequently incomplete and erroneous. This system allowed many patients to ‘slip through the loop,’ often leading both to deteriorating conditions and patient outcomes. A need for a change in process was clearly indicated.

Change Management relies on good communications – at national, state and practice levels, and needs to be implemented in a planned, proactive manner. Communication channels and the decision-making process follow ‘Knowledge, Persuasion, Decision, Implementation and Confirmation’ (Wade, 2006). These decisions need to be made as a collective with consensus among all members of the team involved. The teams appreciated a whole practice approach for the management of chronic conditions and they needed clearly defined roles, boundaries and the authority to carry them out. Decisions on the type of change, perceived and desired outcomes, evaluation process and the Plan-Do-Study-Act cycle were facilitated initially with myself as the driver, but were soon adopted by the whole team as the possibility for improvement became obvious. ‘A critical role of practice leaders is to set the expectations, make quality a priority, and provide the resources to support chronic care and practice improvement programs. There is strong evidence to support the importance of organizational support in improving outcomes’ (Fiandt, 2006).

Accordingly, upon examination, the team identified the required roles to implement the CCM program. These were:

  • A Team Leader/Technical Expert (a GP partner in the practice, responsible for, understanding the implications for the proposed change, determining what to measure and the tools required for measurement, providing guidance on collection and interpretation of data and for ensuring protected time for the Practice Nurse);
  • The Day to Day Leader, (the Practice Nurse), whose responsibility was to oversee collection of the data, implement the register /reminder/recall system and document the effects of the change; and
  • Reception staff, (who played a vital part in sending out recalls at a frequency determined by the team, in accordance with best practice guidelines, and following up patient appointments and reminders when appropriate).

Working Together for Change
To support effective chronic conditions change management the team agreed to determine the size of the practice populations affected by Type 2 Diabetes. We then looked at implementing a consistent method of recording diabetic patients in the GPs Medical Director notes so that they could all be included in the newly cleansed diabetes register. These records would then be used to recall patients at least annually in accordance with best practice guidelines. The team realized that the data to be collected had to be relevant and useful to them and it would only be so if it was accurate. By initially narrowing down the field solely to diabetes, we felt we had a more manageable task and greater hope for successful systems change.

The diabetes registers were time consuming to establish and data cleanse, as inactive and/or deceased patients had to be removed from the outdated incomplete existing registers. Also a search for diabetes did not find all the diabetics because the GPs had not entered the diabetes diagnosis into the patients’ record. It was planned to have completed this process in two weeks and to establish the recall/reminder system in another week. Getting all 14 GPs from both practices to record diabetes as ‘the reason’ for the patients’ consultation in their notes was the major challenge. Methods of encouraging different personalities to conform to the new practice register policy became part of the Plan-Do-Study-Act cycle, as did negotiation and re-negotiation for protected time for the nurse to implement the register. Resultantly, a cheat sheet was developed from the following process for recording information (past history updates, measurements, test results) as the most reliable method of communicating the process and as a ready reference to all concerned. Weekly team meetings were scheduled to evaluate the process and air problems as a quality control measure.

Several processes for creating the diabetes register were investigated. The following process was adopted. An accurate Diabetes Register in Medical Director was achieved by recording patient histories, downloading pathology results and using the diabetes record module where diabetes assessment and/or relevant measurement values were filled out. Patient Histories were edited to add a diagnosis, retrospective history and prescriptions. Diabetes management (recall/reminder) was enhanced by using the Diabetes follow up module. Clinical data was saved into the diabetes record along with assessment dates. A Diabetes Review, at the appropriate interval, was selected and a mail merge, with a recall letter, was sent out to all diabetes patients. Patient safety is assisted by use of the outstanding actions window, alerting the GP as to the reason for the patient visit. This is deleted by using the ‘Mark as Performed’ button when the consultation commences. If the patient does not return for the appointment, an Outstanding Actions list can be printed, checked and re-sent. The Diabetes Annual Cycle of Care was also recorded in the warnings text area as a visual reminder that the patient is on planned care. This process was accompanied by all the relevant MBS item numbers and templates to make this as user friendly as possible. This process is in line with the Department of Health and Ageing’ requirements and is a performance indicator for Divisions of General Practice with Diabetes Programs to encourage and assist general practice to establish electronic register/recall/reminder systems for optimal patient management.

The Evaluation process was very exciting. It took the allotted 3 weeks for all 250 patients from Practice 1 and 167 patients from practice 2 to be added to the register. As soon as the registers were deemed complete by the practice nurses, and all but 3 patients, who were on medication for polycystic ovary syndrome and weight loss, were entered into the recall/reminder system and an Annual Cycle of Care, they were ready for their next plan of action. However, the two concerns that were identified during the process were how to include diet controlled only diabetics on the register and how to address back up if the Day to Day Leader was unable to work. It was decided that the only course of action was to include those patients as they attended the practice in the future. Correct use of the ‘reason for visit ‘and ‘diabetic review’ buttons in Medical Director would ensure their inclusion. A member of the Reception staff had begun Register/recall/reminder input training with the Practice Nurse providing backup when appropriate. The need to monitor recording was also apparent as GPs sometimes forgot to record in the agreed manner.

Benefits All Round
GP outcomes included less anxiety around ‘missing patients’, more time to deal with clinical management and a focused effort on data entry with the obvious benefit of adding to the recall/reminder system. The Practice Nurse felt her work more valued and appreciated the team effort and spirit engendered by the program. The Receptionist felt she had gained a little more control over the appointment book and therefore the anxiety level for all practice members and patients was eased. The number of planned appointments will continue to be monitored to measure this gain. Practice outcomes included financial incentives in the form of a one-off payment for utilizing a patient register/recall/reminder system ($1 per Whole Patient Equivalent (SWPE). Service Incentive Payments of $40 made once a year per patient were triggered by the completion of the Annual Cycle of Care and an $5 per (SWPE) Outcomes payment made to practices each quarter, that reach target levels of care for their patients resulted when diabetic specific Medicare item numbers were used.

All staff had expressed considerable satisfaction with the new improved system. Those directly affected, the GP, Practice Nurse and Receptionist expressed the greatest degree of satisfaction, realizing the capacity building opportunities. They were so inspired by their success that two nurses and one of the GPs asked for assistance in accessing Motivational Interviewing Techniques training to further their knowledge and skills in chronic conditions management and the Reception staff were well on the way to compiling an inventory of lifestyle programs available to patients in and around Launceston. The team hoped to be able to apply these new areas of knowledge, skills and confidence to the management of all chronic conditions in the future.

The outcomes for these two practices concur with the conclusions arrived at by the Divisions Diabetes and Cardiovascular Disease Quality Improvement Project (DDCQIP) study of Register-recall systems in 2004 which found that, ‘There is substantial evidence showing that register-recall systems can be an important tool in providing structured diabetes care using evidence-based guidelines. They have a major contribution to make in improving quality of care as well as facilitating population health monitoring, service planning and provision’ (Georgiou, Burns, Penn, Infante, Harris, 2004).


Fiandt, K. (2006) The Chronic Care Model: Description and Application for Practice. Topics in Advanced Practice Nursing eJournal.

Georgiou A, Burns J, Penn D, Infante F, Harris M. (2004) Register-recall systems – tools for chronic disease management in general practice. Health Information Management Journal, Vol 33 No 2: 31-35.

Harris, P., Mann, L., Marshall, P., Phillips, P., Webster, C. (2008) Guidelines for Type 2
Diabetes, Diabetes Management in General Practice, Diabetes Australia/RACGP.

Funnell, M, Anderson, R. (2003) Psychosocial Aspects, Changing Office Practice and
Health Care Systems To facilitate Diabetes Self-management. Current Diabetes Reports, Vol 3 No 2: 127-133.

Stewart, N (2002) A Guidebook for General Practitioners using Medical Director, Diabetes Register and Recall System, 3-19.

Wade, T. (2006) GP Management Strategy-HealthConnect SA