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:[email protected]
Before July 2005: checklists and forms, Medical software providers