Using care plans to better manage multimorbidity

Mark A Morgan, Michael J. Coates, James A. Dunbar

Research output: Contribution to journalArticleResearchpeer-review

6 Citations (Scopus)

Abstract

Background The health care for patients having two or more long-term medical conditions is fragmented between specialists, allied health professionals, and general practitioners (GPs), each keeping separate medical records. There are separate guidelines for each disease, making it difficult for the GP to coordinate care. The TrueBlue model of collaborative care to address key problems in managing patients with multimorbidity in general practice previously reported outcomes on the management of multimorbidities. We report on the care plan for patients with depression, diabetes, and/or coronary heart disease that was embedded in the TrueBlue study. Methods A care plan was designed around diabetes, coronary heart disease, and depression management guidelines to prompt implementation of best practices and to provide a single document for information from multiple sources. It was used in the TrueBlue trial undertaken by 400 patients (206 intervention and 194 control) from 11 Australian general practices in regional and metropolitan areas. Results Practice nurses and GPs successfully used the care plan to achieve the guideline-recommended checks for almost all patients, and successfully monitored depression scores and risk factors, kept pathology results up to date, and identified patient priorities and goals. Clinical outcomes improved compared with usual care. Conclusion The care plan was used successfully to manage and prioritise multimorbidity. Downstream implications include improving efficiency in patient management, and better health outcomes for patients with complex multimorbidities.

Original languageEnglish
Pages (from-to)208-215
Number of pages8
JournalAustralasian Medical Journal
Volume8
Issue number6
DOIs
Publication statusPublished - 2 Jul 2015
Externally publishedYes

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Comorbidity
General Practitioners
Guidelines
General Practice
Coronary Disease
Allied Health Personnel
Nurse Practitioners
Disease Management
Practice Guidelines
Medical Records
Patient Care
Pathology
Delivery of Health Care
Health

Cite this

Morgan, Mark A ; Coates, Michael J. ; Dunbar, James A. / Using care plans to better manage multimorbidity. In: Australasian Medical Journal. 2015 ; Vol. 8, No. 6. pp. 208-215.
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Using care plans to better manage multimorbidity. / Morgan, Mark A; Coates, Michael J.; Dunbar, James A.

In: Australasian Medical Journal, Vol. 8, No. 6, 02.07.2015, p. 208-215.

Research output: Contribution to journalArticleResearchpeer-review

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