General Practice Oxford

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What are the central principles of effective chronic disease management in general practice?

• Involve the patient’s family where appropriate

• Collaboratively define problems, targets, and goals

• Develop an individualized self-management plan

• Provide a personalized written care plan

• Tailor education to support self-management

• Arrange proactive, planned follow-up

• Monitor clinical outcomes and treatment adherence

• Use stepped-care protocols

• Target specialist services to patients who cannot be managed in primary care alone

• Continually monitor the quality of the management process

Why is supporting self-management essential in chronic disease?

A patient with diabetes may spend only about 3 hours per year with a healthcare professional, but approximately 8,757 hours managing the condition themselves. Therefore, the patient must understand the disease, recognise deterioration, use treatments correctly, and know when to seek help.

What two initial questions should be used to screen a patient with chronic physical illness for depression?

Ask whether, during the last month, the patient has often been bothered by:

1. Feeling down, depressed, or hopeless

2. Having little interest or pleasure in doing things

A positive response to either question requires further assessment.

After a positive initial depression screen, what three additional areas should be assessed?

Ask about:

• Feelings of worthlessness

• Poor concentration

• Thoughts of death

The presence of thoughts of death should prompt a more complete assessment of suicidal ideation and immediate risk.