GAP ANALYSIS TOOL

Components of the Annual Cycle of Care
This table represents the components of the annual cycle of care. Please indicate who
currently undertakes each component and what tools they use to complete the task, for
example if the foot examination is carried out by the practice nurse the tools she may use
may include the best feet forward kit and the feedback form used in that kit. It may be that
the foot examination is undertaken by a podiatrist but if the practice nurse had training
(provided in the best feet forward kit) that person may be able to preform that duty and only
patients with medium or high risk feet are then referred to the podiatrist.

   Component             Who currently          What tools do they        Who else could
                         preforms task?                use?             undertake this task?
                                                                        What training would
                                                                            they need?
Self review          GP & DE
monitoring (find
out criteria)
BP, BMI, Weight,     “
urine check
Symptom review,      “
review BSL level
HbA1c                “
Urine analysis       “
Lipids               “
Foot examination     “                                                 Requires Foot
                                                                       assessment training
                                                                       looking to work with
                                                                       pod an arrange re
                                                                       basic foot care if poss
Eye examination      John Cronin (Maffra)

                         Assessment of Chronic Illness Care
The table below is a series of questions relating how care is delivered, how information is
managed and the resources available and utilised currently in the management of type 2
diabetic patients. With other members in the practice, please note down some key points.
We will further explore this during my next practice visit.

Task                     Comments                         Action                     Priority
Organisation of
Healthcare Delivery
Does the organisation    DE not pushing enough – need     DE & PN & Dietitian to     High
currently have           to start doing this              attend self
measurable and           BSL level is a goal              management course.
reviewed goals for                                        Reference group to
type 2 diabetes                                           look at goals and
management?                                               system to implement
Existing training for    Nil                              Staff to attend training   High/Med
staff (in relation to                                     as appropriate
Approx % of SIP/EPC      60%
payments for diabetes
Delivery System
Does the practice use    Yes pt sees DE and GP on the
planned visits for        same day.
disease review? How       Recall letter is sent. If pt does   Look at developing          HIgh
are these scheduled?      attend the recall remains on        system to ensure pts to
What do these visits      the GP system and when the          rebook and attend
entails – i.e.            pt attends for other reason pt      diabetes specific
preventative              asked to make an appt for           review
interventions, self-      diabetes review – some pt
management support,       don’t compile with this – need
regular assessment        to work on this
Do the all the            Need to work toward this – DE       DE attending self           High
providers involved in     to take on care co-ordinator        management course.
the patient care know     role – system change                Reference group to
their role and                                                plan system change
responsibility in
managing the patient?
Do they just address
what need to or are
they actively involved
in treating the whole
patient? Is there a
‘team leader’?
Are care plans            ? DE to take more active role       As above
completed on              in this
complex patients, if
so, by whom?
Current std practice –    Practice manual contains a          Add pathway into            Urgent
including risk            protocol for diabetes               practice manual –
assessment, how does      management.                         ensure all practice staff
clinic currently assess   6 monthly diabetes review           are aware of pathway
risk, how are high risk   visits – 3 monthly if HbA1c         and know what their
patients                  elevated. Use recall system for     role is
flagged/identified?       this.
What is the current       See DE and GP on the same
process when a            day
patient is sent for       Seen intermittently for DE if
pathology, for            required
example? Can you          Seen by GP for other reasons
identify if the patient   intermittently
has been prior to next
visit? What is the
process if patient did
not go? Who is
responsible for
looking at this? How
do you flag IGT – how
are they monitored?
Do all GP’s in clinic     Yes as per protocol                 As above
follow same pathway
What is working/not       Group of pts that don’t want        Reference group to          High
working currently         to follow review process            address
                          Missing services – pod and          Develop relationship
                          dietitian                           with services
                          Cost to pts                         Reference group to
Decision Support
Is patient                GP diabetes handbook
management based on
What criteria, if any,    Subjective, different for all     ? Look at developing      Low
does the practice use     GPs                               criteria – in house
to make referrals to      Depends on GPs own area of        training etc
specialists?              strengths
                          Endo in Traralgon, Physician
                          Sale or City
What tools etc does       CME                               Develop in house          Low
the practice use to       Need to start doing more as a     training
keep up to date with      practice
current practice in the   With registrars have
care of chronic           educational seminars
disease/type 2            Diabetes Australia
diabetes?                 website/info
Practice Level
Does the practice         No DE or PN to go to course       DE & PN to attend self    High
document self-                                              management course
management needs?
If so, who takes on
this role? What is the
process undertaken to
do this?
Currently is self-        Nil                               As above and learnings    High
management support                                          to be disseminated to
provided or offered to                                      reference group and
the patient? If so,                                         systems developed to
who by? What is the                                         Incorp in pt
process for this?                                           management
Are there any             Looking to develop support        Develop support group     Med
behaviour change          group. To include group
interventions and         dietitian sessions if possible.
peer support              DE – developed info kit for       Work on this with         Med
conducted by              newly diagnosed – trying to       reference group
practice/others in the    add to this, work on that with
referral pathway – if     ref group
so who? How is this
done booklets etc,
trained personnel,
integral part of
routine care?
What support,             Often recommend spouse
education is offered      comes with pt for DE
to families and
patients to address
their concerns – how
is this offered and by
Identification of         Need to contact pod and           Caroline to contact and   Urgent
current/local referral    dietitian to engage               ask in they are
pathways                                                    interested in project
Current relationship
with those in the
identified referral
How do you envisage
the reference group
working? Do you have
any ideas about a
Clinical Information
Has the patient           Happy data is accurate –      Nil
register been audited     ongoing process
in the past 3 months
to ensure data is
entered correctly; all
type 2 diabetics are
captured? Inactive
patients are not
recorded on registry?
How consistent is the
recall system used?
How does the practice
use this system?
How do you currently
flag patients for
follow up/ At risk
Data collection
What information do
you currently collect
for the division, the
Commonwealth and
NPCC? How is the
data collected?
Community Linkages
Does the practice         Looking to commence support   See previous comment
referral patients to      group
Australia? How is this
done? Is there a key
person to do this?
Human Resources
Availability of key       Dr Peter Stevens
person within clinic to
facilitate project
Care co-ordinator –       DE
currently. Capacity to
undertake this role
(maybe someone
external to clinic?)
What outcomes is the      -training                     Identify needs and      Urgent
practice looking for                                    develop training
through participating                                   framework and budget
in stage 1                -system support               PDSA cycle for change   High
implementation of                                       management
project (champion,        -improve pt care              Develop and             High
resources available,      -increase/improve pt          implement systems
improving pt              engagement in mngmt of CD
outcomes, etc)

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