Table 2 Extract from an intervention facilitator's practice visit reports, modified to protect anonymity
| Â | Needs | 1stVisit | 2ndVisit | 3rdVisit |
|---|---|---|---|---|
Staff Roles | Role specification and clarification Dedicated person to contact the AHPs | Clarify the different roles of practice staff - practice manager (PM), nurse (PN) and receptionist. Regarding referral: practice manager would be the key person available for other health professions to contact. | Practice has currently established the guidelines of Team Link project. (The facilitator) Encouraged the practice to organizing a staff meeting in view of strengthening the internal team. | Introduced new strategies to deal with the ever increasing amount of paperwork. Regular staff meetings required to discuss ways of improving chronic disease management and how to optimize the existing resources. |
Communication | Foster better interpersonal relationship with AHPs Investigate the quality and availability of services by AHPs in private practice Contact details required frequent updates | Consider face to face meeting with AHPs | An improvement in communication with AHPs noticed, however the feedback from the AHPs regarding the referrals is expected to improve with time. The practice was visited & followed up by several AHPs frequently on demand. Exercise Physiologist, Podiatrist, Psychologist & Dentist are among them. Practice is currently seeking the service of a Dietitian. The Division is trying to refer them to a reliable Dietitian who can visit the practice when necessary. PM has an idea of allocating a staff member (PN) to update & maintain their AHPs database. | Significant improvement observed in the feed back process from AHPs as result of communicating via email and the feedback is electronically archived for each patient in the database. They are finalizing arrangements to recruit the dietitian. Organized a dietitian, he is paying regular visits to the practice. A staff member has been allocated to update and change database. |
Systems for Recall | Set up effective operational recall system | Arrange staff to improve patient recall system Practice manager will update the new Medicare items, eg 75 health check | They have improved the CDM registers & recall systems. They are currently in the process of updating Medical Director Software & its data bases and seek some assistance from our IT department. | Â |
Patient Education | Need for patient to self-manage for patient safety and patient empowerment | Â | The ongoing plan in management of patients with chronic diseases is constantly reviewed & more patient education sessions have to be organized. They ask for some resources (Educational materials/pamphlets etc) from us. | Supplied with educational materials (i.e. pamphlets leaflets etc.) for patients on general self management. Initiating a patient education session |