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Person Centred
Care Planning
Ros Rolleston RN Primary Health Care Nurse & Educator [email protected]
December 2014
Learning Objectives Discuss practice funding
Describe Medicare eligibility & requirements
Develop person centred approach to chronic disease management
Improve multidisciplinary team communication
Practice Funding
Practice Nurse PIP $25000:1000 SWPE for RN working 12.6hrs/wk Rural and AMS loading
Diabetes PIP
Asthma PIP
CDM Rebates GPMP/TCA – 721/723
$258.55
Review GPMP/TCA – 732x2 $144.10
Contribution to RACF care plan – 731 $70.40
Contribution to another’s care plan – 729 $70.40
Monitoring & support by GPN – 10997 $12
http://www9.health.gov.au/mbs/search.cfm?q=721&sopt=S
GP Time Based MBS Rebates Asthma Cycle of Care, 2546/52/58
$37.05 – $105.55
Diabetes Cycle of Care, 2517/21/25 $37.05 – $105.55
Mental Health Care Plan, 2700 series $71.70 – $134.10
GP consultation item numbers no longer claimable on the same day as CDM services
http://www9.health.gov.au/mbs/search.cfm?q=2700&sopt=S
MBS Eligibility
Chronic illness 6m
Clinical decision of the GP
Mental health
Reduced capacity to self care
Intellectual or physical disabilities including kids
Obesity, BP, lipids, glucose, LFTs
RACF, hospital discharge
http://www9.health.gov.au/mbs/fullDisplay.cfm?type=note&q=A37&qt=noteID&criteria=721
MBS Requirements
Document consent
Written plan
Person agreed goals
2 ongoing providers
Collaboration with other providers
http://www9.health.gov.au/mbs/fullDisplay.cfm?type=note&q=A37&qt=noteID&criteria=721
Review & Renew Periods
3-6 months review
12-24 months care plan
Clinical guidelines
Exceptional circumstances
MBS Online
http://www9.health.gov.au/mbs/fullDisplay.cfm?type=note&q=A37&qt=noteID&criteria=721
Person Centred Assessment
Team Based Care
Collaborative team meeting
Agree on GPN & GP roles
Patient identification
Appointment scheduling
Template selection
Database research
Organisation of recalls
Together we can achieve
Auto Fills & Short Cuts – GP I have discussed the care planning process with my
patient who has given their consent to have a GPMP/TCA developed with the GPN
I have updated the past history and medications
Illnesses to be included:
Other Providers to be included:
Review period: 3 months
Auto Fills & Short Cuts – GPN Referred by… for preparation of an initial care plan for…
Discussed the process and billing
Discussed referrals and potential costs
Review period of 3 months due to…
Consent given to proceed
Today’s assessment –
Setting the Scene
1 hour appointment
Arrange for no interruptions
Active listening
Body language
Open ended questions
Include person in decisions
Review History
Look at the billing
Set reason for visit
Update reminders and recalls
Load template
Autofills
Go through the whole file
In the Beginning... BMI
BP, P & regularity, SpO2, BGL
Informed consent
Medications
Pathology
Family history
Smoking, alcohol
Needs Assessment Rate your health 1-10
Main health concern
Duration of illnesses
Knowledge of illnesses
Nutrition
Is your diet healthy
Breakfast, lunch, dinner
Fruit & vegetables
Meats, dairy & bread
Water & salt
Processed foods, takeaways, snacks
Activity
How active is your lifestyle
Activities you enjoy
Barriers to activity
Specific exercise
Are you stable on your feet
Mental Health & Wellbeing
Daily routine
Do you ever feel sad or alone
Do you have any worries
Sleep patterns
Substance use
Self harm, suicidality
Medications
Concurrence
Side effects
Complimentary therapies
Regular Pharmacist
HMR
Vaccination
Influenza
Pneumococcal
Hep B
dTpa
MMR
Zoster
http://www.health.gov.au/internet/immunise/publishing.nsf/content/Handbook10-home
Medical Guidelines
22% CVD
10% CRF
68% with diabetes have CVD or CRF
Mortality rate in Indigenous & socioeconomic disadvantaged groups
CVD, Diabetes & CRFAIHW 2014Cardiovascular disease,
diabetes & chronic kidney disease: Australian facts: prevalence & incidence
Cardiovascular Risk Assessment TC, LDL, TC:HDL ratio
Triglycerides
LFTs
BP, P, BGL
Statin, antiplatelet
ED
ECG
Renal Protection eGFR
Microalbuminuria
ACR
BP, BGL
U/E/C, K+
ACE or ARB
NSAID
Microvascular Circulation
Vision
Feet
Lungs
Cognition
Further Investigation
FBE
CRP
Na+
B12
Vitamin D
Goal Setting
Personal Goals Person centred
Maximum of 3
Stages of change
Health coaching
SMART Goals SMall Authentic Re-evaluate Timeframe
Advanced Care Directives Document persons wishes for care & treatment
before they are unable to speak for themselves
Discussion with family & GP discussion
Enduring guardian has the responsibility for health care
Enduring power of attorney has the responsibility for financial and real estate affairs
http://www.advancecaredirectives.org.au/
Collaboration
Referrals & TCA Dietitian, Exercise Physiologist, Podiatrist
Physiotherapist, Osteopath, Chiropractor
Optometrist, OT, Speech Pathologist
Pharmacist, HMR
Dentition
CNC, ACAT
Specialists
List all team care members on care plan
Handover Cruical for successful CDM
Person relays the messages
Post-it note
Phone call
Intranet message
Face to face
CDM Folder Engages person
Personal role
Personal responsibility
Team communication
Houses a contemporaneous and complete health history
My Health Plan
Thank the person for coming
Congratulate them on becoming an active participant in their health care
Invite the them to call if they have any questions
Acknowledge Person
Nurse Case Managers
Ongoing contact
Coordinating care
Disease surveillance
Independent of GP
GPN can be TCA member
Person Centred Medical Home
23, 10997, 10987, 732, 2517, 2546, 2713, 2715
Regular appointments
BP, INR, BGL monitoring
Health coaching, goal attainment, education
Weight & activity monitoring
Vaccination
ECG, Spirometry, Dopplers
Forward Planning
Business ModelConsultations Item Number GP Time GPN Time Billing
GPMP 721 10 45 144.25
TCA 723 15 114.30
Reviews 732 30 45 432.30
GP Consults 23 80 296.40
GPN Monitoring 10997 75 60.00
ECG 11700 31.25
Bulk Billing 10991 238.70
TOTAL year 120 180 $ 1317.20
TOTAL month
$109.77
TOTAL hour $263.44
Web Resources Better Health Channel
CVC Program
Flinders University
Health Change Australia
MBS Online
RACGP
Thank You
