join MGPN

• What is Health Management Coaching (HMC)?
• What evidence supports Health Management Coaching?
• What benefits will Health Management Coaching provide to GPs?
• Who should be referred?
• Referring to Health Management Coaching
• What happens next?
• What does a coaching session involve?
• Client Information Brochures
• For more information

What is Health Management Coaching (HMC)?

HMC is a joint initiative between MGPN and St Vincent’s Hospital Admission Risk Program (HARP). The program aims to reduce avoidable hospital admissions for people with either cardiovascular disease (CVD) or Type 2 Diabetes and to promote self-management of their chronic disease. 

HMC provides clients with telephone-delivered support from an Accredited Practicing Dietitian to assist them with achieving the modifiable risk factor targets set by the Heart Foundation. Risk factors addressed include: 

• Cholesterol levels
  
• Blood sugar levels
  
• Blood pressure
  
• Diet 
• Weight and waist circumference
  
• Smoking
  
• Physical activity
  
• Medication compliance
• Vaccinations (diabetes)
• Foot checks (diabetes)
• Eye checks (diabetes)
  
  

Clients are either referred to the program by their GP and/or Practice Nurse, or they are recruited directly from the cardiology wards or diabetes clinic at St Vincent’s Hospital, Melbourne. 

What evidence supports Health Management Coaching?

 Cardiovascular Disease

Two randomised controlled trials have proven this program to be highly effective in improving the coronary risk factor status of clients with CVD. 

A four year follow up of the second study found that four years after randomisation, coaching decreased hospital admissions by 16% and hospital bed days by 20% when compared to usual care.

• First coaching study
  
• Second coaching study

Recent evaluation of 2008-2010 data has demonstrated that it continues to be an effective model for improving risk factor status of people with CVD.

• Eight years on and still effective: CVD risk factor status of patients graduated from Health Management Coaching (HMC), 2008-2010 

Type 2 Diabetes

A recent study has also demonstrated that telephone coaching is an effective intervention that improves risk factor status and adherence to treatment guidelines in clients with Type 2 Diabetes.

• Telephone Coaching Improves Glycaemic Control and Achievement of Treatment Targets in Type 2 Diabetes

What benefits will Health Management Coaching provide to GPs?

 HMC is designed to be co-operative with the GPs care of the patient, not compete with it.

The program can provide a number of benefits to GPs including:

• The ability to use the Health Management Coach as a health care provider on Team Care Arrangements (MBS Item: 723) without affecting the client’s allocation of five allied health visits.
• Progress reports will be regularly provided to the GP. These reports can assist with the Care Plan Review (MBS Item: 732)
• Clients may potentially see their GP more often to request lipid tests, blood pressure testing and discuss their medications as the client is encouraged to take a more proactive role in their disease management.

For more information regarding Chronic Disease Management (CDM) Medicare Items please go to the following links:

• Fact Sheet for CDM Medicare Items
• Questions and Answers on the CDM items
  

Who should be referred?

Cardiovascular Disease

The program is appropriate for clients who:

1. Have had a previous coronary event: 
   •    ● Myocardial infarction
   •    ● Angina with abnormal investigation
   •    ● Percutaneous coronary investigation
   •    ● Coronary artery bypass graft surgery
   OR
   Have non coronary vascular disease:
   
   •    ● Peripheral vascular disease
   •    ● Cerebrovascular disease
   •    ● Aortic aneurysm
2. And, have had a presentation or an admission to hospital in the past 12 months or are at a high risk of doing so.

Clients with any of the following are not eligible for the program:

• Aged >75 years
  
• Unable to provide informed consent
  
• Drug and alcohol problems
  
• Cognitive impairment
  
• Complex co-morbidities (e.g. cancer)
  
• Unable to easily or accurately communicate over the telephone due to severe hearing impairment or lack of telephone access

Type 2 Diabetes

The program is appropriate for clients who:

• Have Type 2 Diabetes; and
  
• Have had a presentation or an admission to hospital in the past 12 months due to their diabetes or they are at high risk of doing so.

Clients with any of the following are not eligible for the program:

• Unable to provide informed consent.
• Drug and alcohol problems.
• Cognitive impairment.
• Complex co-morbidities (e.g. cancer).
• Unable to easily or accurately communicate over the telephone due to severe hearing impairment or lack of telephone access.
  

Referring to Health Management Coaching

1. Assess if the patient meets the specified recruitment criteria to join the program. The PEN Clinical Audit Tool can be used to assist with identifying eligible clients in your practice.
2. Complete one of the following referral templates:
   •    ● HMC Medical Director referral template  (Right click and Save Target As...)
   •    ● HMC Genie referral template  (Right click and Save Target As...)
   •    ● Victorian Statewide Referral Form (VSRF) http://www.gpv.org.au/content.asp?cid=11,137&VSRF#get2009vsrf
     
                         OR
        ● Use Health Management Coach as a health care provider on a Team Care Arrangement (MBS Item 723)
     
3. Fax the referral/Team Care Arrangement to the Health Management Coach at the MGPN through the secure fax referral line on (03) 9348 0750.

What happens next?

The Health Management Coach contacts the client to organise an initial assessment at the MGPN consultation suite in Carlton. If it is difficult for the client to attend their initial assessment at this location, this assessment can be conducted at the GP practice or over the telephone.

At the initial assessment, the Health Management Coach will obtain more information regarding the client’s cardiovascular risk factors and baseline measurements for blood pressure, weight, waist circumference and height.

Within the next two weeks the telephone coaching sessions begin. 

What does a coaching session involve?

All coaching sessions are conducted over the telephone, with calls initiated by the Health Management Coach (at least once/month). The Health Management Coach determines the client’s knowledge of their risk factors, targets for these risk factors and lifestyle factors that affect their health.

Where gaps in knowledge, behaviour or drug treatment are identified, the client is educated by the Health Management Coach in these areas, after which the client and the Health Management Coach negotiate goals to be achieved prior to their next coaching session. The process repeats itself at subsequent coaching sessions until most risk factor targets are met. 

Client Information Brochures

• Cardiovascular Disease
• Type 2 Diabetes 
   

For more information

If you would like further information about the Health Management Coaching program please contact:

Brodie Preston
Health Management Coach and Accredited Practicing Dietitian
Melbourne General Practice Network
Ph: (03) 9347-1188
Fax: (03) 9348-0750
Email: brodie.preston@mgpn.com.au 

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