Chronic Disease Management (CDM) The new world of care planning

1. Chronic Disease Management (CDM)The new world of care planning Dr Alison Sands MBBS FRACGP North East Valley Division of General Practice 14 June 2005

2. Community Care Plan Discharge care Plan Care Plan review Contribution to care plan Residential aged care plan Up to Nov 2005 GP Management Plan Team Care Arrangements From July 2005 The old world: & the new:

3. The Old World

4. The New World

5. Advantages of new items • Increase care planning options for GP • Expands patient eligibility • Increase assistance from practice nurse • More flexibility in who can prepare plans & perform reviews

6. GP Management Plan • Chronic condition (>6 months)or terminal condition • With OR WITHOUT multidisciplinary care needs

7. Creating a GP Management Plan • GP (usual or another in same practice) +/- practice nurse • Assess patient needs • Management goals • Actions for patient • Treatment • Services • Document plan • +/- copies to others if patient agrees

8. GP Management Plan • No other providers needed to be involved in patient care • No need for collaboration with other providers • Item 721 $120

9. Team Care Arrangements • Chronic or terminal condition • ALSO complex care needs requiringongoing care from a multidisciplinary team (GP plus 2 other health or care providers- does not include carer)

10. Creating Team Care Arrangements • GP +/- practice nurse • Patient consent (steps, sharing info, cost, record) • Identify services/ providers • Collaborate with other providers (face, phone, fax, email) • Document goals, providers, management by each, patient actions • Copies to others • Item 723 $95

11. Reviews – Items 725 & 727 Reviews may be prepared by the usual GP OR by another GP from the same practice or, if the patient has changed practices, by their new GP • Review Of GP Management plan (Item 725) • Needs, goals, actions, treatments, services • Document any changes • Set new review date • Review Of Team Care Arrangement (Item 727) • Discuss with patient • Collaborate with other providers • Document any changes • Distribute copies $60 each

12. How often?

13. Flexibility in timing *CDM services can also be provided more frequently in’ exceptional circumstances’ • where there has been a significant change in the patient’s clinical condition or care circumstances • (such as development of co-morbidities or complications, deteriorating condition, illness/death of carer etc), • that require a new GP Management Plan, Team Care Arrangements or review service. Write reasons on Medicare voucher or patient invoice

14. CDM items are: • Eligible for 100% Medicare incentives • Eligible for Bulk Billing incentives

15. Role of practice nurse • Practice nurse/ Aboriginal health worker/ other health professional • Assist preparing &/or reviewing GPMP or TCA by • Assess & identify needs • Make arrangements for services • GP must review & confirm all elements • GP must see patient • No extra Medicare item for nurse involvement

16. Allied Health Items Access requires: • Prepare GP Management plan PLUS Team Care Arrangement OR • Contribution to Aged Care Home plan (Item 731)

17. SIPs for Diabetes, Asthma & Mental Health & the new items • SIPs for asthma, mental health & diabetes cannot be claimed if you have already claimed a GP Management Plan & vice versa GPMP OR SIP • Unless the patient has complex multidisciplinary needs beyond that covered by the SIP, then you can claim all: GPMP + TCA + SIP

18. Further information • www.health.gov.au (use A-Z Index tool to go to Chronic Disease Management) • Department of Health and Ageing (02) 6289 8735 • Qu to:epc.items@health.gov.au • Before July 2005: checklists and forms, Medical software providers