Improving the Care to Patients with Chronic Conditions

Background: I work in the sub-district around Tzaneen, based at Letaba Hospital. The population is 350 000. The areas have 31 clinics. Since 2005, the coordinator for Chronic Conditions and I planned a strategy together to improve the care to patients with chronic conditions. Our focus is on the four conditions: hypertension, asthma, epilepsy and diabetes mellitus. Initially, the record system comprised a patient retained booklet, a chronic conditions register with name, condition, medication and monthly visits of patients, as well as a 6-monthly medication prescription.Aims: Train and support clinic nurses to manage and monitor patients with chronic conditions. Ensure availability of relevant equipment. Ensure availability of medication. Develop and implement a user-friendly clinic-based record system. Evaluate control of patients. Methods: A quality improvement strategy was implemented where 3-monthly meetings held, training done and improvement plans developed. Meetings were attended by nurses from the 31 clinics, pharmacists and managers. Between meetings the clinics were visited to evaluate the equipment, medication, record system and control of patients, with a standard checklist. Information was fed back to the role-players during the meetings and exceptional performance was noted and awarded. New plans were developed from this information and again implemented. Results: Since 2005 eleven training meetings and seven evaluations has been completed. Improvement is as follows: Implementation of the record system: 29% to 60%; Hypertension control: 72% to 84%; Asthma control: 38% to 68%; Epilepsy control: 38% to 79%; Diabetic control: 53% to 56% Conclusions: With a process, which cost the chronic conditions coordinator and a family physician an average of two working days per month, the quality of care to patient with chronic conditions was improved and proven with the results from the quarterly evaluations done.