Ochre’s industry leading “Health Outcomes Program”

Here at Ochre Health we are dedicated to maintaining the long-term health of our patients, and our Chronic Disease Management program is an essential aspect of our overall approach to comprehensive, efficient healthcare.

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What is CDM?

Chronic Disease Management (CDM) refers to the strategies that GPs undertake to monitor and address the health concerns of patients living with chronic or terminal medical conditions. In Australia, conditions such as diabetes, asthma, heart disease, kidney disease, depression, osteoporosis, arthritis, and cancer account for 9 in 10 deaths. Chronic disease affects 1 in 5 Australians, with around 40% of Australians over 45 having multiple chronic conditions. CDM is an essential strategy in combating the debilitating effects of chronic disease through structured, ongoing care. CDM is generally carried out in two modes: a GP Management Plan (GPMP), or Team Care Arrangement (TCA). If a patient is considered by their GP to be eligible for CDM services, a health plan will be arranged by the attending medical staff and the patient, in which goals will be set, and progress will be reviewed on a regular basis.

CDM is an essential strategy in combating the debilitating effects of chronic disease through structured, ongoing care.

 

What is Ochre’s Approach to CDM?

Ochre Health has implemented an industry leading “health outcomes program”, where the progress of our patients is monitored through indicators such as blood pressure, smoking rates and BMI, then measured against the national average, the Ochre average, and Ochre’s clinical targets. We have set ourselves very ambitious annual targets, meaning that the staff in our clinics are doing their best to help patients to achieve their goals, so that they are less likely to need hospitalisation.

We have set ourselves very ambitious annual targets, meaning that the staff in our clinics are doing their best to help patients to achieve their goals, so that they are less likely to need hospitalisation.

Our innovative CDM strategy involves a thorough annual assessment of each patient, led by a doctor and/or a dedicated practice nurse.  To monitor our patients’ progress we use a patient-centred management plan, which is arranged by collaborating health professionals, who work with the patient to identify their specific healthcare needs and plan health goals for the upcoming year. As soon as the annual assessment has been completed, it is followed up with GP or nurse-led reviews and reassessments scheduled every 13 weeks, as shown below.

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Ochre Health is also committed to improving the health of Australia’s indigenous population. We measure the health improvements recorded for our CDM patients, and any gaps between indigenous and non-indigenous patients are noted and assessed. The results are used to help us improve the quality of the health of indigenous people as part of the Closing the Gap campaign.

 

outcomesWhat are the benefits of Ochre’s health outcomes program?

With a clearly structured, long-term healthcare plan, our patients will find it easier to understand their condition(s) as well as manage their appointments, medication, exercise and dietary regimes. We use data from our 31 rural and urban health centres to monitor our success in improving the health of our CDM patients, and have found that our outcomes program is achieving positive results. Our most recent set of results shows that Ochre Health’s CDM strategy is helping patients and medical staff hit targets, with 40% of patients meeting their health goals, meaning that our health outcomes are 10% higher than the national average.

 

Call Ochre Health today to find out more about our health outcomes program.

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