Team Learning Packs · Chronic disease · Team-based care
Chronic disease management: a team-based approach
Chronic disease care is multi-professional by definition. This pack combines clinical updates on type 2 diabetes and chronic kidney disease with a structured team huddle on how the practice coordinates chronic disease care — MyMedicare registration, care plans, recall systems, and team roles.
Individual learning by role.
Each clinical team member completes their profession's module before the team huddle. Where a role has no profession- specific module yet, that member joins the huddle and contributes from their discipline.
GP (RACGP / ACRRM)
t2dm sglt2i intensification ›Pair with chronic-kidney-disease module if your patient mix warrants it. Also relevant: cv-risk-lipids.
Registered nurse / Midwife
chronic kidney disease ›Chronic kidney disease module is profession-applicable; t2dm module is GP-prescribing-focused but the audit applies to nursing-led chronic disease care plans.
Pharmacist
t2dm sglt2i intensification ›Module is clinically rich for community pharmacists managing diabetes therapy reviews; consider also CKD module for medication reviews.
Physiotherapist
Huddle-only role
No profession-specific module yet — join the huddle and contribute on exercise prescription, allied-health referral pathways, and how physio fits the chronic disease care plan.
Psychologist
Huddle-only role
No profession-specific module yet — join the huddle and contribute on mental health comorbidity in chronic disease, MHCP integration, and behaviour-change support.
Chronic disease team huddle
Duration: 60 minutes. One person chairs (typically the practice administrator). No slides required — the agenda below is the structure.
Agenda
0-10 min
Map the chronic disease workflow: how does a new T2DM diagnosis flow through this practice? Who does what, in what order, with what handoffs?
10-25 min
Identify the bottlenecks: where does the workflow break down? Common candidates: recall lapses, allied-health referral follow-up, medication-review timing, patient self-management support.
25-45 min
MyMedicare and care plan discussion: is the practice using the available structured-care items consistently? Where could nurse-led or pharmacist-led reviews extend the GP's reach?
45-60 min
Implementation: one workflow change to trial. Common candidates: standardised recall list, nurse-led pre-visit screening, pharmacist-led medication review.
Discussion prompts
- Which chronic disease has the weakest team-based workflow in this practice right now, and why?
- Are we using nurses and pharmacists at the top of their scope, or are routine tasks staying with the GP because we haven't restructured?
- How do we share clinical reasoning across professions in this practice — is it handoff documentation, case discussions, or informal corridor conversation?
- Where does the patient experience of our chronic disease care break down — appointments, communication, continuity, or follow-up?
Implementation actions
A starter list. Pick one or two to trial in the next four weeks.
- Designate one chronic disease and audit the current recall list for the next quarter.
- Trial nurse-led pre-visit screening for chronic disease consults for the next month.
- Integrate a pharmacist-led medication review at a defined interval (e.g. annually) for patients on five or more medications.
- Schedule the next chronic disease team huddle in 8-12 weeks to review the trial.
CPD eligibility
The huddle counts as Reviewing Performance for each clinical participant under self-attestation. Each member logs the huddle as a separate RP activity (suggested 1.0 hour) in addition to the module hours. The implementation-trial follow-up audit is additionally loggable as Measuring Outcomes.
Run this pack with your team.
The pack itself is free to use — no PracticaCPD subscription required to view the huddle template, run the meeting, or log the result manually. Pro / Practice subscriptions unlock the modules and the team-progress dashboard.