Opinion: Care coordination to improve chronic disease management

Nearly a quarter of Australians cite that they feel like GPs are inaccessible^₁. With a widening pay gap between GP specialists and other specialists, and fewer medical students than ever selecting general practice as a career, there is an urgent need to ensure that the coalface of our health system can continue to support and care for the general population’s health needs.

So how then can we achieve more with fewer resources? As a practising GP, having worked most of my career in regional and rural Australia, I believe that part of the solution involves using telehealth to support, rather than replace, GP interactions.

I have experienced firsthand why health equity is good for patients. I worked in rural and regional areas witnessing the challenges faced by them, and the pressure on the healthcare industry. My colleagues and I have been inundated with demand for appointment bookings and regularly need to empathise with our patients who struggle to have access to specialists.

Access to health care is limited by two constraints: affordability and availability. When it comes to the latter, the post-COVID backlog has created an increased patient load for doctors and has resulted in a bottleneck for patients seeking to access care — particularly specialised care, which is expensive.

This is especially acute in regional and rural settings. My time working as a GP in regional Australia has been some of the most rewarding work I have ever done; however, due to the distance from major city centres, rural GPs have even less access to specialists and allied healthcare services — particularly for those needing treatment for chronic conditions².

In Australia, potentially avoidable deaths from chronic conditions account for a third of all deaths. Further, one in two people have at least one chronic condition, and 60% of people over 65 years old have more than one chronic condition³.

The gold standard treatment for patients suffering from chronic conditions — such as diabetes, heart failure, insomnia, IBS, sexual dysfunction or chronic kidney disease, to name a few — require ongoing and coordinated specialist care, provided by a team of professionals working together. With the patient overload on GPs, it’s just not possible for the GPs to properly coordinate all the disciplines required to treat chronic conditions for them to work together efficiently.

Current telehealth providers that service some of these conditions do nothing to help with the real problem: coordination of the team and continuity of care. Most telehealth platforms run by large technology companies are predicated on the worst form of medicine — quick, cheap and ineffective. These models may work for the technology companies, but they ultimately fail in reaching any public health goals. They are based on one-off, anonymous ‘consultations’, with no patient history or continuity of care. In some cases, patients simply fill in a form and get a script for what they think they need to ‘treat’ their condition based on answering some form questions.

So how then do we use telehealth in an appropriate way to improve patient outcomes? In my view, the only appropriate use of telehealth involves using digital platforms to support an ongoing relationship built on a model of continuity of care in partnership with a patient’s primary GP. This reduces the load on the GP and resolves the two chief constraints facing patient care: affordability and availability. When it comes to the latter, the post-COVID backlog has created an increased patient load for doctors and has resulted in a bottleneck for patients seeking to access care — particularly specialised and allied health care, which is expensive and is hard to find.

For instance, we all know the difficulty in having professionals attend multi-disciplinary conferences and create treatment plans. When was the last time you heard about a cardiologist and nephrologist talking to your patients? Or a psychologist, dietician and diabetes educator to create or update a treatment plan for the patient’s GP? Digital technology makes that possible. This is what patients expect from health care, and technology allows for it to be done quickly and efficiently, freeing up the GP to attend to more acute issues.

And patients are supportive of being assisted by technology — 62% of Australians are already using technology to manage their health. However, 69% of healthcare providers still think a lack of integration with existing systems is a barrier to offering connected care⁴. For chronic conditions, telehealth is a ‘quick fix’ in nature, but lacks the coordinated expertise among physicians to provide optimal patient outcomes.

The future of treating chronic conditions is about having access to a connected team of multidisciplinary specialists and allied health professionals, who are working off a common plan and communicate with each other — and the patient’s primary GP — seamlessly and at the touch of a button.

In today’s interconnected world where we work remotely and shop online, health care has lagged far behind the business and commercial industries in the digital transformation — but it’s getting closer. Sophisticated digital health platforms that provide continuity of care in partnership with GPs do exist. The Vityl platform allows a patient to see a specialist promptly and also connects them to a whole managed, multidisciplinary team of specialist and allied health professionals. It also allows the practitioners to seamlessly coordinate the patient’s care, giving the patients access to group classes and online learning programs for their conditions, and feeds back reports and their treatment plans to the GP, all through a centralised digital platform. In taking some of the workload off the GPs, it allows for more efficient higher rebate paying consultations with patients, resulting in better patient outcomes.

As an industry, we need to create solutions that empower healthcare professionals to effectively diagnose, manage and treat patients with chronic health conditions in a multidisciplinary way — no matter where they live.

A dedicated team of health professionals treating patients via a virtual platform will undoubtedly take the pressure off GPs to follow up on adherence to management plans and reduce the frequency of preventable hospital admissions.

^References

^{1. Coordination of health care: experiences of barriers to accessing health services among patients aged 45 and over, Summary - Australian Institute of Health and Welfare, 2020}

^{2. Coordination of health care: experiences of barriers to accessing health services among patients aged 45 and over, Summary - Australian Institute of Health and Welfare, 2020}

^{3. National Strategic Framework for Chronic Conditions, reporting framework: indicator results, Summary - Australian Institute of Health and Welfare, 2022}

^{4. National Digital Health Strategy and Framework for Action, 2018}

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