General practices report Winter Strategy initiatives are improving care for at-risk patients. Anecdotal feedback from NCPHN’s Practice Support Officers to enrolment and implementation of the Winter Strategy is generally pleasing, with patients feeling more valued and supported.
The Winter Strategy aims to support general practices to keep their most vulnerable patients with chronic diseases well, and to reduce their likelihood of being hospitalised this winter. It’s available for general practices and Aboriginal Medical Services in the Tweed Valley, Richmond Valley and Clarence Valley regions. There are 27 practices enrolled in the 2017 Winter Strategy.
Being part of the Winter Strategy program means that patients are given a special sick day action plan to help them manage their chronic disease, they receive a weekly phone call to monitor their health and wellbeing and have extra allied health support available to them if necessary.
In the Clarence Valley, three practices let us know how the strategy to register and support chronic care patients in additional ways has been going.
Aaron Sweeney is the practice nurse at Union Street Family Medical Practice in Yamba.
The practice has 31 patients enrolled in the Winter Strategy program, most with COPD or diabetes. The patients seem to like it and the staff are finding it a valuable program.
Aaron has also found that patients tend to disclose more about their health status during the weekly phone call than they do in person.
“We have one gentleman who was constipated but was too embarrassed to mention it while he was at the practice, but he was able to tell me during a phone call.
“And another patient would answer the phone very breathless and tell me he’d just come up the stairs, but I know he only has three steps in the house…so we are picking up things that we wouldn’t otherwise.”
According to Aaron, patients are enjoying the weekly phone contact and they are feeling the practice is invested in their health. It’s improving the relationship they have with both their nurse and doctor.
At Yamba Private Clinic, Sarah Hope is assistant to Practice Manager Diane Hope.
The practice has registered 25 patients into the program and Sarah has created a checklist at the front desk for staff to fill in when a Winter Strategy patient either phones in or calls in at the practice, which has been helpful to keep track of this cohort.
Sarah and Diane have been making the weekly phone calls to patients.
“One lady we rang let us know that a friend of hers, who was not enrolled, was too sick to come to the practice and we were able to check on that patient,” said Sarah.
Initially Sarah wondered if the patients would be annoyed by a weekly phone call, but she said they welcome the contact.
“Another patient mentioned to us on the phone that she thought she was due for a shingles vaccination and we were able to organise an appointment for her to have that done.”
Around half of the 25 patients enrolled haven’t wanted to fill in the Winter Strategy patient survey on the iPad and Sarah has printed a copy of the survey for them to fill out.
Ros Hollis is the practice nurse at Clarence Medical Centre in Maclean and said that their nine enrolled patients loved the weekly phone contact.
One COPD patient’s carer said she was really appreciating being part of the Winter Strategy because being involved in the care plan has given her more confidence about her role. She told Ros she loved being more involved in the care plan and felt like she now knew what she was doing.
Ros said the carer reported that she was giving the patient more regular Ventolin when symptoms indicated it would be helpful to do so, and she was feeling more confident about when to give prednisone.
Patients are happy about the weekly phone check up. Ros calls on Monday afternoons to see how the patient has gone over the weekend.
“I’ve called back two patients recently after speaking to them on the phone. They’d not improved as much as we would have liked, so it was necessary to get them back into the practice.
“They know that we will squeeze them in and they are certainly feeling more valued,” said Ros.
And in addition, the weekly phone call made Ros realise that one patient needed extra help at home and Ros was able to help the patient gain My Aged Care benefits.
There have been some difficulties with the survey. Ros handed out the survey in hard copy form and then tried to enter the results online. She found she had no idea whether the results had been downloaded and would appreciate clearer instructions on downloading the survey material.
Another benefit of the Winter Strategy was that staff at the practice feel more ‘linked up’ to their cardiac rehab nurse.
“During the Winter Strategy process, the cardiac rehab nurse has provided us with resources to manage CCF patients in daily ways and this is an extra benefit that’s come to the practice,” said Ros.
NCPHN looks forward to more feedback about the Strategy as the year progresses.
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