Patient Review and Planning

70% of participating clinicians agreed, or strongly agreed, that winter strategy triggered more thorough and systematic care planning than they were usually able to provide.

2. Review and Update Existing Patient Care

1.What are the person’s current concerns?

Are there any particular concerns at the moment? Deal with these or make arrangements for it.

Consider using a relevant score to show progress on concerns, eg  Medicoach Wellness wheel (call Bernadette on 6618 5412 for more information if you did not attend the Medicoach Health Coaching training in 2018).

2. How are they progressing on their goals?

Were you able to play golf? Were you able to visit your daughter? Did the HbA1c go down? Any new goals?”

3. How is a review of their condition/s looking?

How are the key symptoms or markers or measures for each long term condition?

4. Is the care team working as a team?

Can you make it easier for others in the team? Do the allied health and specialists have all the information they need? Update on who is doing what with the patient.

5. How is the patient going with key health behaviours?

Alcohol, smoking, exercise, weight/ diet, sleep, skin care

6. How is their resilience and motivation at the moment?

Staying as active as possible – having social supports and contacts, hobbies, doing some exercise

Is care support sufficient? Is carer under too much pressure?.

Motivation for self-care and choices. E.g. Why is it good to smoke vs good to not smoke?

7. How are the medications going?

Is the current list correct, is inhaler technique correct? Is the person taking the correct dose in the right way? Is there confusion about purpose of meds or fear about taking them?

8. Does the person know their action plan and how to use it?

“Do you know what to do if….  How will you know if you should …… “ Get the person to say the plan back to you – don’t repeat the plan to them.

9. How confident are they about what they need to do to stay well?

Of all the things that are important for keeping you well, which are you confident about, and which not so confident about? What would make you more confident?”

10. Are there any logistical issues with appointments?

Do they have the planned reviews and follow up booked in? Are there logistical issues to be resolved?

From Dr Dan Ewald, Lead Clinical Advisor NCPHN, thanks Dan.