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Using care plans to better manage multimorbidity

Morgan, Mark A. J., Coates, Michael J. and Dunbar, James A.A 2015, Using care plans to better manage multimorbidity, Australasian medical journal, vol. 8, no. 6, pp. 208-215, doi: 10.4066/AMJ.2015.2377.

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Title Using care plans to better manage multimorbidity
Author(s) Morgan, Mark A. J.
Coates, Michael J.
Dunbar, James A.AORCID iD for Dunbar, James A.A orcid.org/0000-0003-0866-4365
Journal name Australasian medical journal
Volume number 8
Issue number 6
Start page 208
End page 215
Total pages 8
Publisher Australasian Medical Journal
Place of publication Sorrento, W.A.
Publication date 2015
ISSN 1836-1935
Keyword(s) Multimorbidity
care plans
collaborative care
depression
diabetes
heart disease
Summary 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.
Language eng
DOI 10.4066/AMJ.2015.2377
Field of Research 111799 Public Health and Health Services not elsewhere classified
Socio Economic Objective 920299 Health and Support Services not elsewhere classified
HERDC Research category C1 Refereed article in a scholarly journal
ERA Research output type C Journal article
Copyright notice ©2015, The Authors
Free to Read? Yes
Use Rights Creative Commons Attribution licence
Persistent URL http://hdl.handle.net/10536/DRO/DU:30077972

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Every reasonable effort has been made to ensure that permission has been obtained for items included in DRO. If you believe that your rights have been infringed by this repository, please contact drosupport@deakin.edu.au.