The Wellness Clinic
Overview
The Wellness Family Medical Centre established a self-management wellness clinic for patients with identified chronic disease. The region where the practice is located has a high population of Aboriginal and Torres Strait Islander people who experience a significantly lower life expectancy compared to the rest of NSW. The clinic focused on improving patients’ health literacy and encouraging lifestyle changes to allow them to manage their own health more effectively.
200 patient appointments were conducted within the first six months
Model
Comprehensive data cleansing using PENCAT software was undertaken, patients with three or more co-morbidities were identified, and a disease register was created. Brochures introducing the nurse clinic service were handed out to patients by reception staff, boosting patient interest in the new service. Initial 45-minute appointments to discuss health concerns and care planning enabled comprehensive information gathering and ensured patients’ individual health needs and goals were understood. Care plan development and GP consultation for identified treatments (medication, pathology, health coaching etc) attracted MBS funding. A follow up 30-minute appointment to check the progress of any referrals to additional services and to track and review patients’ care plans was scheduled.
Life expectancy for Aboriginal and Torres Strait Islander peoples in Australia is 8-11 years less than non-Indigenous people.
Funding
All consultations were bulk–billed utilising eligible MBS chronic disease management items and there was no out–of–pocket expense to patients visiting the nurse clinic.
A total of 1164 appointments were conducted between January 2019 and May 2020
Outcome
There was a huge uptake in the nurse clinic, with over 200 patient appointments conducted within the first six months and a total of 1164 appointments between January 2019 and May 2020. The development of a Chronic Disease Register kept track of patient numbers. The team approach to patient care is evident and the nurse clinic was heavily supported by lead GP, Dr Alex Hoyle, administrative staff, and the lead nurse.
Dr Hoyle commented that the Wellness House aims to ‘focus on health, rather than illness’ which is the primary aim for the nurse clinic as it relates to empowering patients to self-manage their chronic disease.
‘As doctors, we focus a lot on the numbers, on the medication, on the illness because that’s our training. Whereas, with nursing, the focus is more on symptoms, activity, and social coordination. Having two sides to the equation really allows us to do a far more integrated assessment for the patients with health plans and (achieve) positive outcomes.’
The clinic has made care delivery more systematic and financially rewarding for the GPs, evidenced by the following successful outcomes:
- Increased patient requests for this service
- Increased nurse satisfaction
- Increased practice revenue