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The Chronic Condition Management (CCM) Quality Improvement (QI) Workbook is a simplified and practical guide for implementing CCM through continuous Quality Improvement (QI) activities. It focuses on enhancing continuity of care, improving patient outcomes and increasing practice efficiency by shifting from volume-based care towards structured, regular care planning and preventative care model. It recognises that this is a substantial behaviour change for patients and practices, requiring a change in perspective, models, systems and attitudes toward care.
The QI workbook links to existing resources related to MyMedicare and the Chronic Condition Management and seeks to enable general practice to determine readiness for participation in the CCM, complete the registration process (if needed) and sets out actionable steps to improve your practice’s model of care people with a chronic condition.
Practices may wish to view and complete the workbook in whole or choose specific modules that are most relevant for your practice.
4 CCM QI Workbook - Section 4 Activities
- Tips and Tools for maintainng QI momentum
- 4.1 Pre activity : CCM Practice Readiness Checklist
- 4.1.1 Preparing for Chronic Conditions Management and MyMedicare patient registration
- 4.2.1 Engage your Practice
- 4.2.1 Activity – Swim Lane - Roles and Responsibility
- 4.2.2 Explore the benefits of MyMedicare with your practice team
- 4.2.3 Explore Chronic Conditions Management changes with your practice team
- 4.3 Raise patient awareness
- 4.3.1 Activity - Communication Action Plan
- 4.3.2 Review and Strengthen the Process
- 4.3.3 Review and strengthen communication
- 4.3.3 Activity – Scripts: phone, SMS, email and website
- 4.4 Recall existing CCM patients
- 4.5 Check in, review and celebrate
6 CCM QI Workbook Appendices
- 3.1. MFI and PDSA - Identifying Active Patients & Linking to MyMedicare Program
- 3.2 MFI and PDSA - Correcting Missing Demographic Information
- 3.3 MFI and PDSA – Accurate Recording of Demographic Data and Lifestyle Risk Factor
- 3.4 MFI and PDSA – Data Coding Accuracy for Chronic Conditions
- 3.5 MFI and PDSA – Team awareness, desire and readiness
- 3.6 MFI and PDSA - Patients eligible for chronic disease management planning or review
- 3.7 MFI and PDSA – Patients with chronic conditions – Diabetes
- 3.8 MFI and PDSA – Patients with a care plan billed in the past 12 months
- 3.9 MFI and PDSA – Patient Engagement and Reminders
- 3.10 MFI and PDSA - Reducing Missed Appointments
- Appendix 1 - Completed Example Team roles template - Roles and Responsibilities for MyMedicare and Chronic Conditions Management
- Appendix 1 - Team roles template for general practices
- Appendix 2 – Model For Improvement and PDSA Template
- Appendix 2.1 - Model for Improvement Template
- Appendix 2.2 - PDSA (Plan-Do-Study-Act) Template
- Appendix 4 - Claiming workflow - Care Plan (GPCMMP 965 or 92029)
- Appendix 5 - Claiming workflow Care Plan Review (GPCCMP Review Appointments)