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

Dr Alison Sands MBBS FRACGP

North East Valley Division of General Practice14 June 2005

The old world: & the new:

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

Community Care Plan (patient lives at home)

Discharge Care Plan (prior to discharge from hospital or day hospital)

Residential Aged Care

Prepare 720 $206.75722 (Private)

$175.75 (85%)

Contribute 726 $41.65728 (Public)

$41.65 730 $41.65

Review 724 $103.40 724(review item 722)

$41.65 730 $41.65

The New WorldGP Management Plan

Team Care Arrangements

Prepare/co-ordinate

721 $120 723 $95 721+723(=old Item 720 “preparation of Care Plan”)$215

Review 725 $60 727 $60

Contribute or Review of plan (including on discharge) prepared by:

Other provider 729 $41.65

Aged Care Facility 731 $41.65

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

GP Management Plan

Chronic condition (>6 months) or terminal condition

With OR WITHOUT multidisciplinary care needs

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

GP Management Plan

No other providers needed to be involved in patient care

No need for collaboration with other providers

Item 721 $120

Team Care Arrangements

Chronic or terminal condition

ALSO complex care needs requiring ongoing care from a multidisciplinary team

(GP plus 2 other health or care providers- does not include carer)

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

Reviews – Items 725 & 727Reviews 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

How often?

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

CDM items are:

Eligible for 100% Medicare incentives

Eligible for Bulk Billing incentives

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

Allied Health Items

Access requires: Prepare GP Management plan PLUS

Team Care ArrangementOR

Contribution to Aged Care Home plan (Item 731)

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

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