Table 5 Summary of included studies: examining use of CDM plans related to diabetes self-management in the Australian context

To give practice nurses a greater focus on prevention and education on chronic disease management.

9 general practices in southeast Queensland

26 healthcare professionals

Exploratory qualitative research

Time pressures and unreliable MBS information were barriers. Employing a nurse, team-based approaches, recall systems, and using only selected MBS CDM item numbers were enablers to uptake for general practitioners

To explore the perceptions and experiences of the staff and patients with Nurse-led CDM plans

Primary healthcare settings

(Queensland)

A total of

3 PMs,

5 Nurses

5 GPs,

patients (n = 38)

A concurrent mixed-method study was situated within

the paradigm of Pragmatism

The collaborative involvement of doctors was an intrinsic factor in patient acceptability of nurse-led care that facilitated positive outcomes for nurses. Chronic disease management delivered by nurses was acceptable, feasible, and sustainable.

To investigate whether GPMPs and TCAs, and reviews improve the management and outcomes of patients with diabetes by cdmNet

Patients with type 1 or 2diabetes mellitus from across Australia (including metropolitan, rural and regional communities

Patients with type 1 or 2 diabetes mellitus (n = 577)

A before-and-after study of

prospectively collected data

There were significant improvements in process and clinical outcomes for patients on a GPMP or a GPMP and TCA with regular review and no significant change without reviews

To investigate the perspectives of primary

care patients in receipt of Medicare-funded team care for CDM

Two purposively selected general practices: one urban and one regional practice in Queensland

Patients (n = 23)

Qualitative study

If there is a sense of personal obligation and sufficient financial incentive, and considering patient expectations and preferences, patients are likely to engage with a structured team care approach to CDM.

and decision

To draw on the implementation experience of the South Australian GP Plus Practice Nurse Initiative for developing the chronic disease management role of practice nurses.

147 General Practices in Adelaide

Three focus groups:

41 practice nurses and one group:

10 practice nurse coordinators and practice nurse mentors.

Secondary analysis of qualitative data contained in the Initiative evaluation report.

(GP Plus Practice Nurse Initiative Final Evaluation Report 2007—2010)

Support is needed at two levels to advance the role of practice nurses as managers of chronic disease and to assist practice nurses in building their skills.

Support is also needed to ensure that systems are ready to include the practice nurse within the practice team

To understand Chinese migrants living with T2DM experiences in Australia and their culturally specific diabetes management needs, habits, and expectations in the

GP clinics (two Melbourne and one Sydney)

Patients/providers (n = 18/8)

Case study

Chinese migrants look to their peers more for diabetes management because healthcare professionals are not part of supporting the community. Also, redesigning diabetes management services align with collectivism which is appropriately much with patient’s expectation

To review studies investigating the experience of self-management support in patient and provider interactions and shaping goals.

Systematic

review and qualitative

synthesis

Interactions are affected by consultation times, patient self-blame and guilt, desire for autonomy, and beliefs about what constitutes practical self-management skills.

Healthcare professionals remain in a position of authority because of limiting opportunities for control to be shared with patients and shared understandings of social context

To evaluate health outcomes in chronic disease management interventions for adults with chronic diseases implemented in primary or community care settings

Systematic review with narrative synthesis

Self-Management support is the most frequent Chronic Care Model intervention associated with significant improvements statistically and for diabetes and hypertension, predominately

To examine utilization rates of GPMPs or TCAs, characteristics, and relationship with hospitalization for cohort participants of Central East Sydney over the period 2006–2014

Primary and Community Health Cohort/Linkage Resources (Central and Eastern Sydney)

Patients with chronic disease (n = 30,645)

A cross-sectional study

Well-targeted GPMPs and TCAs in the CES area

with no relationship with prevented hospitalizations in the CES region.

To describe the characteristics of people in Central and Eastern Sydney (CES), NSW, who

had a (GPMP) and claimed for at least one private allied

health service and its relationship with fewer hospitalizations over 5 years.

NSW Centre for Health Record Linkage

Patients (n = 5771)

Prospective longitudinal study

Well-targeted usage of allied healthcare. Physiotherapy services were associated with less avoidable hospitalizations.

To examine person the proportion of claims for preparation and review of GPMPs or TCAs and allied health services in New South Wales (NSW) by demographic features, chronic conditions, and levels of disability between 2006 and 2014 for any change in uptake

NSW Centre for Health Record Linkage (CHeReL)

Patients (n = 264,732)

Longitudinal study

Increasing usage of care plans and allied health services. Increasing care plan reviews, but with suboptimal proportions, may indicate poor continuity of care.

.

To explore the current activities of a sample of Australian private health insurance (PHI) funds to

support the care of people with chronic conditions and a permitted change for

a broader range of chronic disease management (CDM) services.

PHI sector and hold a senior management role. Invitations to participate were sent via email to 19 PHI organisations (Sydney)

10 Senior management role

Qualitative

After 10 years, insurers are still in the early stage of implementing and evaluating CDM activities, with the primary category of activities in health navigation, disease management, and health coaching programs and care coordination services.

Challenges and constraints with patients and other healthcare services and stakeholders were investigated

Evaluate clinical outcomes after standard care between baseline and 12 months and assess changes in participants’ self-reported HR-QoL, risk of hospital admissions, disease-specific risk, and explore predictors of treatment uptake, response, and compliance

Primary care practice (Sydney)

Patients with diabetes (n = 589 and 7750 in the comparison group)

A cohort study design with a comparison group and a case-series study design

Self-management behaviours, the baseline lifestyle, and other health behaviours of the sample participants recorded at the start of the program enable GPs to understand individual needs and quality care better.

To explore the effectiveness of cdmNet (an eHealth tool) for chronic disease management in general practice settings

database of 800 General practices (metropolitan Melbourne)

34 clinical and non-clinical staff

Qualitative case study

Changes in clinical and organizational routines, team-based approach, allocating resources, training, and supportive leadership can support a structured CDM approach for health innovations

To explore patients’ experience with chronic conditions in interprofessional collaborative practice in primary care

Integrative review

Three themes were developed: Interacting with healthcare teams, valuing convenient healthcare, and engaging in self-care with an emphasis on patients’ interprofessional collaborative practice

To explore the perspectives of healthcare staff delivering care to people

with diabetes regarding an existing healthcare service

community health service in regional Victoria

21 Healthcare professionals

Qualitative

A more integrated, team-focused, and accessible Model of care (MoC) is needed in a regional area for better outcomes, and the barriers were investigated

Secondary analysis of baseline data from the CONNECT randomized controlled trial linked to Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) claims.

Twenty-four primary care services in Sydney, Australia. Study sites were spread across greater Sydney, including the Blue Mountains region, and one service was an Aboriginal Community Controlled Health Service.

905 trial participants from 24 primary health care services

Secondary analysis

The risk of CVD in people with or at elevated GPMPs is under-utilized overall. Well-target high-needs populations and facilitated allied health access but without associated with improved CVD risk management