Chronic Disease Support

References and resources required in the management of chronic disease.

Register/Recall Systems

Definitions

Register – a method of identifying patient populations based on specific criteria, often generated from clinical software databases. Registers may be used for prevention or management purposes.

  • Examples: chronic disease registers, age register, at-risk registers.

Recall – a follow-up of clinically significant, urgent or abnormal test results.

  • Crucial that the patient attends the practice
  • Examples: abnormal PAP result, elevated INR.

Reminder – a notification for prevention or management purposes.

  • Helps to manage screening and cycles of care
  • Helps to provide continuity of care
  • Examples: diabetes, immunisations, cervical screening.

RACGP Standards

Royal Australian College of General Practitioners (RACGP) Accreditation 4th Edition Standards have several criteria relating to the use of registers, recalls and reminders.

Criterion 1.3.1 (Health Promotion and Preventive Care)

“Our practice provides health promotion, illness prevention and preventive care and a reminder system based on patient need and best available evidence.”

The RACGP requires a systematic approach to prevention and health promotion for patients, using registers, recall and reminder systems, incorporating protection for patient privacy and confidentiality.

Criterion 1.5.3 (System for Follow Up of Tests and Results)

“Our practice has a system for the follow up and review of tests and results.”

Practices should have a documented policy for the follow up and review of tests and results. At a minimum, this policy should incorporate guidelines on:

  • under what circumstances or for which conditions a recall or reminder may be made
  • how often recalls/reminders will be prompted, along with tracking of recalls/reminders
  • staff members accountable for each step of the follow-up procedure
  • methods of notification and follow-up (letters, templates, email, SMS, phone calls etc)
  • detail the systems for both recalls and reminders (may be illustrated with a flowchart).

“In a group practice, it is ideal for all GPs to have the same system for the follow up of tests and results. This consistency will ensure that all members of the practice team are fully aware of the practice system. If there are different follow up systems in place for different doctors in the practice, this needs to be very carefully documented to ensure the follow up of tests and results is managed effectively across the whole practice.”

Patient Consent

Criterion 4.2.1 (Confidentiality and Privacy of Health Information)

Explicit consent is not required for participation in practice-level registers for the purpose of prevention or management activities, however patients should be informed that the practice uses a recall and reminder system (via the practice information sheet or by a sign in the waiting room).

Criterion 1.3.1 (Health Promotion and Preventive Care)

Patients must be notified if the practice participates in state or national registers, such as ACIR or the Cervical Screening register, or that the patient be made aware they may opt out of such registers. Notification and options for participation may be collected on a “new patient form”.

Register, Recall and Reminder System Resources

For questions regarding registers, recalls and reminder systems, please contact your primary health care support officer or browse the following resources:

Guides to Setting up Register, Recall and Reminder

Chronic Disease Health Resources

Northern Territory PHN (NT PHN) have put together links that will help you quickly navigate to important resources around chronic disease management.

Chronic Obstructive Pulmonary Disease (COPD)

Lung Foundation
COPD-X

Diabetes

Diabetes Australia
National Diabetes Services Scheme
JDRF Australia 
Australian Institute of Health and Welfare
Australian Diabetes Educators Association 
Australian Diabetes Society

Chronic Kidney Disease (CKD)

Kidney Health Australia
Australian Institute of Health and Welfare
The Department of Health
RACGP

Stroke

Stroke Foundation
Bupa

Coronary Heart Disease

Heart Foundation
Heart Research Australia
The Department of Health 

Dyslipidemia

NPS Medicinewise
MSD Manual
Heart Foundation Australia 

Hypertension

Heart Foundation Australia
The Royal Children's Hospital Melbourne
Australian Family Physician

Fetal Alcohol Spectrum Disorder

National Organisation for Fetal Alcohol Spectrum Disorders
Health Direct Australia

Gestational Diabetes Mellitus (GDM)

Australian Family Physician
Diabetes Australia
Australian Institute of Health and Welfare

Chronic Hepatitis B

Australian Family Physician
HepBHelp

Depression

Depression.com.au
HelpGuide.org
Beyondblue
ReachOut

Anxiety

Beyondblue
Australian Psychological Society
Headspace

Rheumatic Heart Disease (RHD)

RHD Australia
Heart Foundation
Australian Institute of Health and Welfare

Asthma

Asthma Australia
National Asthma Council Australia