Chronic Disease

Core Generalist

Knowledge

CG.K.1

Compare the differences between acute and chronic disease

CG.K.2

Describe the relevant anatomy, physiology, pathology of chronic conditions

CG.K.3

Discuss the principles of diagnosis, management and monitoring of chronic diseases and comorbidities and how these may relate to the disease course over time

CG.K.4

Describe the natural history, prognosis, treatment and management of chronic conditions commonly encountered in general practice

CG.K.5

Explain the environmental, social, cultural and economic factors which contribute to the development and persistence and prognosis (or progression) of chronic conditions

CG.K.6

Describe how the presence of comorbidities can affect disease prognosis and management

CG.K.7

Discuss the current best evidence for their management and the potential harms of pharmacological and nonpharmacological forms of treatment

CG.K.8

Identify relevant risk factors for future health events in the context of chronic disease, including adverse effects of medications and other medical interventions used to manage chronic disease

CG.K.9

Identify currently funded programs to assist in the management of chronic conditions

Skills

CG.S.1

Use screening procedures to identify asymptomatic individuals at risk for common chronic diseases

CG.S.2

Manage common chronic conditions including ischaemic heart disease, stroke, lung cancer, colorectal cancer, depression, type 2 diabetes, arthritis, osteoporosis, asthma, chronic obstructive pulmonary disease and chronic kidney disease

CG.S.3

Manage co-occurring mental health sequelae of chronic physical health conditions in the developing child/adolescent

CG.S.4

Use current evidence-based guidelines for chronic disease management

CG.S.5

Evaluate the physical, psychological and social levels of function and disability

CG.S.6

Implement practical and pragmatic approaches to managing chronic diseases and comorbidity

CG.S.7

Work with patient and family and allied health providers to develop a chronic care plan that includes self-management (health care plans, ie GP management plan and team care arrangements, mandate the involvement of allied health providers)

CG.S.8

Utilise techniques that support and maintain healthy lifestyle changes, including motivational interviewing, appropriate referral to other healthcare and specialist providers

CG.S.9

Be responsive and empathetic to fluctuations in the physical and mental state of patients with chronic diseases

CG.S.10

Assess the patient’s understanding of their condition and provide education

CG.S.11

Involves the patient in management decisions

CG.S.12

Assist patients to contact others with similar conditions and/or relevant support organisations

CG.S.13

Use systematic approaches to case management, care co-ordination and advocacy, including effective follow up and review processes for chronically ill patients

CG.S.14

Embrace new technologies that have been demonstrated to improve health outcomes

CG.S.15

Understands Chronic Disease Management Medicare item numbers indications and requirements and their role in patient care to enhance chronic disease outcomes

CG.S.16

Provide support to patients and their families throughout the illness, and especially at times of crisis and change in the disease or treatment

CG.S.17

Use medical record systems appropriate to the care of patients with chronic conditions, including effective long term follow up, tracking and prompted systematic periodic review

CG.S.18

Utilise computer records and eHealth measures in disease management and prevention, including the use of electronic communication between other healthcare provider s and for quality improvement audits

CG.S.19

Have strategies for time management, taking into consideration heavy demands on time and effort when managing complex medical problems and chronically ill patients

Attributes

At.6

Compassion

At.13

Pragmatism

At.17

Resourcefulness