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Combined Chronic Disease Care Plan at Indian Ocean Territories Health Service - Sung Kye Lee
A abstract with Sung Kye Less at the APNA 2018 National Conference - Nurseforce for the Future - The Australian Primary Health Care Nurses Association's 10th annual conference for nurses working in primary health care.
Previously at Indian Ocean Territories Health Service each chronic condition was dealt with individually, resulting in unnecessary and duplicated recalls for pathology and clinical measures. Patients were subjected to many call-backs to the health facility and the clinician had to undertake repetitive collection of pathology and clinical measures without the opportunity for constructive consultation.
Combined Chronic Disease (CCD) care system was developed to guide clinicians to deliver an evidence-based, patient-focused and holistic approach to attend to complex and multiple chronic illnesses. The CCD takes into account the patients’ cardiovascular risk and all other co-morbidities.
CCD is enabling clinicians to feel confident that the care they are delivering is both relevant and necessary to the patient. Clinicians feel more empowered and knowledgeable about the patient and their illness when they can follow and attend to tailored items for each patient. Patients are also satisfied with this timely and efficient manner of consultation.