Dr John Troy Medical Centre recruited a respiratory technician and implemented a lung function clinic, in order to provide more proactive care to patients with chronic respiratory diseases. The health service further developed their recall systems and use GP Management Plans in order to provide better healthcare for people with chronic disease, in their community.
Location: Fremantle, Western Australia.
Staff: Solo GP, 3 administration/receptionists, a practice manager and 2 practice nurses.
To begin the process of identifying patients at risk of developing a chronic disease, the practice team started by identifying patients who were either smokers or ex smokers. Initially, the reception staff encouraged patients to complete a ‘lung health check’ questionnaire while waiting for their appointment. The questionnaires were then sorted and forwarded to the practice manager and practice nurses (PNs) for coding in the clinical software.
Patients: 3300 active patients.
Aim: To develop a system for the management of people with chronic respiratory illnesses, by providing a program that aligns with modern
Dr John Troy established his solo practice in the heart of Fremantle 30 years ago. The practice bulk bills and caters to a mixed population including retired and current port workers and seafarers, office workers and Indigenous patients. Dr Troy had previously been involved in a wave of the APCC Program, and so had experience in quality improvement and the Collaborative methodology and welcomed the opportunity to take part in the Chronic Obstructive Pulmonary Disease (COPD) and Chronic Disease Prevention and Self Management (CDPSM) wave. Dr Troy wanted to further improve his systems of care by establishing a system for proactively identifying patients who are at risk of developing a chronic disease and providing them with preventive care.
Following a discussion with a respiratory physician at the Fremantle hospital, Dr John Troy’s health service established a lung function clinic. They engaged a respiratory technician once a week to come to the health service and perform spirometry tests on COPD patients, asthmatics and those identified as smokers and ex smokers. The reception staff phone these patients and book a time for them to come in to the clinic. The lung health clinic has now been in operation for six months.
Since joining the Program, Dr Troy feels he has developed the necessary support and resources to take on the extra workload of running various clinics and providing proactive care for those patients with, or at risk of developing a chronic disease. The health service staff are working more efficiently as a team to support one another and relieve the pressure from their solo GP.
Other outcomes include:
- Since beginning the Program and setting up the lung function clinic, the COPD register has grow from 34 to 69 patients.
- In addition to increasing their number of spirometry assessments performed, the team have initiated a recall system for all patients with positive results for COPD, emphysema and asthma.
- They have extended their nurse-led clinics to include treatment for patients with respiratory diseases, as well as improved follow-up and management of these patients.
- The nurses routinely update and record basic data for all patients attending the clinic, such as weight and blood pressure, etc.
- Strong partnerships have been developed with external healthcare providers.
- Recognition and coding of smokers and exsmokers has improved dramatically.
- GP Management Plans are being used more efficiently for continuity of care, and provide an additional income stream.
- Dr John Troy was given the opportunity to present at a national APCC learning workshop about the improvements and activities occurring at the practice, and has also presented at meetings with the Division and other health services.
- Patient responses to the lung health check questionnaire and spirometry recalls has been very positive.
In order to increase their care for patients with a chronic disease, Dr John Troy’s practice used a local respiratory technician and established a lung function clinic. Six months into the clinic, patients with COPD, asthma and emphysema are being cared for more proactively and the health service is using GP Management Plans to ensure
continuity of care. The team is also more confident when identifying patients who are ex or current smokers and educating them about lung related
“The APCC Program provides a basis for the practice to develop better systems and processes, which supports a practice to focus on preventative care. Staff also have
a better idea of the importance of their own position within the team.”
– Dr John Troy, Practice Principal
Level 5, 19 Grenfell St Adelaide SA 5000
PO Box 3645 Rundle Mall SA 5000
ABN 21 122 939 299
T +61 8 8422 7400
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The Australian Primary Care Collaboratives Program is funded by the Australian Government Department of Health and Ageing and delivered by Improvement Foundation Australia. © Improvement Foundation 2010.