Chronic Disease Management Plans Medicare Benefits Schedule Items Current January 2014 This information has been taken from the Medicare Benefits Schedule Whilst all care has been taken, Rural Health West recommends any enquiries are directed to Medicare as this information is subject to change.

Introduction The Medicare Benefits Schedule provides a series of Medicare Item numbers which provide rebates for medical practitioners to manage chronic or terminal medical conditions by preparing, coordinating, reviewing or contributing to chronic disease management plans (CDMP). 1

1.Preparation of a GP Management Plan (item 721) 2.Coordination of Team Care Arrangements (item 723) 3.Contribution to a Multidisciplinary Care Plan or Review of a Multidisciplinary Care Plan (item 729) 4.Contribution to a MDCP, resident in an aged care facility or review of a MDCP, resident in an aged care facility (item 731) 5.Review of a GP Management Plan or Coordinate a Review of Team Care Arrangements (item 732) The Chronic Disease Management Items are: 2

What is a chronic disease? These Medicare Benefits Schedule items apply to a patient who has at least one medical condition that has been present (or is likely to be present) for at least six months or is terminal. 3

Item number DescriptionMBS Fee Minimum Claiming period* For GPs to manage chronic or terminal illness Available to patients in the community Available to private in- patients of a hospital being discharged Available to public in- patients of a hospital being discharged Available to residents of a residential aged care facility Requires a comprehensive written plan Consult with at least two providers A practice nurse or AHW may assist a GP ** 721 Preparation of a GP Management Plan (GPMP) $ months XX X 723 Coordination of Team Care Arrangements (TCA) $ months XX 729 Contribution to a Multidisciplinary Care Plan (MDCP) $ months X 729 Review of a Multidisciplinary Care Plan (MDCP) $ months X 731 Contribution to a MDCP, resident in an aged care facility $ months XXX 731 Review of a MDCP, resident in an aged care facility $ months XXX 732 Review of a GP Management Plan $ months XX X 732Review of Team Care Arrangements $ months XX Chronic Disease Management (CDM) Items at a glance

Patient eligibility 5

Preparation of a GPMP, Coordination of a TCA, Review of a GPMP or Coordination of a Review of TCA (Items 721, 723 and 732)  Are available to: i.patients in the community; and ii.private in-patients of a hospital (including private in- patients who are residents of aged care facilities) being discharged from hospital.  Are not available to: i.public in-patients of a hospital; or ii.care recipients in a residential aged care facility. 6

Should generally be undertaken by the patient's usual medical practitioner. The patient's "usual GP" means the GP, or a GP working in the medical practice, who has provided the majority of care to the patient over the previous twelve months and/or will be providing the majority of GP services to the patient over the next twelve months. The term "usual GP" would not generally apply to a practice that provides only one specific CDM service. Cannot be claimed by general practitioners when they are a recognised specialist in the specialty of palliative medicine and treating a referred palliative care patient under items However the referring practitioner is able to provide the CDM services. Chronic Disease Management Items 721, 723 and 732 7

Contribution to a Multidisciplinary Care Plan or Review of a Multidisciplinary Care Plan - Item 729  Is available to: i.patients in the community; ii.both private and public in-patients being discharged from hospital.  Is not available to care recipients in a residential aged care facility. 8

Contribution to a Multidisciplinary Care Plan or Review of a Multidisciplinary Care Plan for a resident in an aged care facility – Item 731 This item is available to care recipients in a residential aged care facility only. 9

Chronic Disease Management Plan Requirements 10

Preparation of a GP Management Plan A comprehensive written plan must be prepared describing: a.the patient's health care needs, health problems and relevant conditions; b.management goals with which the patient agrees; c.actions to be taken by the patient; d.treatment and services the patient is likely to need; e.arrangements for providing this treatment and these services; and f.arrangements to review the plan by a date specified in the plan. 11

In preparing the plan, the provider must: a.explain to the patient and the patient's carer the steps involved in preparing the plan; b.record the plan; c.record the patient's agreement to the preparation of the plan; d.offer a copy of the plan to the patient and the patient's carer; and e.add a copy of the plan to the patient's medical records. Preparation of a GP Management Plan 12

Coordination of Team Care Arrangements The medical practitioner must consult with at least two collaborating providers, each of whom will provide a different kind of treatment or service to the patient. One of the minimum two service providers may be another medical practitioner. The patient's informal or family carer can be included in the collaborative process but does not count towards the minimum of three collaborating providers. 13

When coordinating the development of a TCA, the medical practitioner must prepare a document that describes: a.treatment and service goals for the patient; b.treatment and services that collaborating providers will provide to the patient; and c.actions to be taken by the patient; d.arrangements to review (a), (b) and (c) by a date specified in the document. Coordination of Team Care Arrangements 14

The medical practitioner must also: a.explain the steps involved in the development of the arrangements to the patient and the patient's carer; b.discuss with the patient the collaborating providers who will contribute to the development of the TCAs and provide treatment and services to the patient under those arrangements; and c.record the patient's agreement to the development of TCAs; d.give copies of the relevant parts of the document to the collaborating providers; e.offer a copy of the document to the patient and the patient's carer; and f.add a copy of the document to the patient's medical records. Coordination of Team Care Arrangements 15

Contribution to a Multidisciplinary Care Plan or to a Review of a Multidisciplinary Care Plan A MDCP is a written plan that is prepared for a patient by: a medical practitioner in consultation with two other collaborating providers, each of whom provides a different kind of treatment or service to the patient, and one of whom may be another medical practitioner; or a collaborating provider (other than a medical practitioner) in consultation with at least two other collaborating providers. For a patient who is not a care recipient in a residential aged care facility 16

When contributing to a multidisciplinary care plan or to a review of the care plan, the medical practitioner must: a.describe the treatment and services to be provided to the patient by the collaborating providers; b.prepare part of the plan or amendments to the plan and add a copy to the patient's medical records; or c.give advice to a person who prepares or reviews the plan and record in writing, on the patient's medical records, any advice provided to such a person. Contribution to a Multidisciplinary Care Plan or to a Review of a Multidisciplinary Care Plan For a patient who is not a care recipient in a residential aged care facility 17

Contribution to a Multidisciplinary Care Plan or to a Review of a Multidisciplinary Care Plan A multidisciplinary care plan in a Residential Aged Care Facility (RACF) means a written plan that: is prepared for a patient by a collaborating provider (other than a medical practitioner), in consultation with at least two other collaborating providers; and describes, at least, treatment and services to be provided to the patient by the collaborating providers. For a resident in an aged care facility 18

When contributing to a multidisciplinary care plan or to a review of the care plan, the medical practitioner must: prepare part of the plan or amendments to the plan and add a copy to the patient's medical records; or give advice to a person who prepares or reviews the plan and record in writing, on the patient's medical records, any advice provided to such a person. Item 731 can also be used for contribution to a multidisciplinary care plan prepared for a resident by another provider before the resident is discharged from a hospital or an approved day-hospital facility, or to a review of such a plan prepared by another provider. Contribution to a Multidisciplinary Care Plan or to a Review of a Multidisciplinary Care Plan For a resident in an aged care facility 19

Review of a GP Management Plan When reviewing a GP Management Plan, the medical practitioner must: a.explain to the patient and the patient's carer the steps involved in the review; b.record the patient's agreement to the review of the plan; c.review all the matters set out in the relevant plan; d.make any required amendments to the patient's plan; e.offer a copy of the amended document to the patient and the patient's carer; f.add a copy of the amended document to the patient's records; and g.provide for further review of the amended plan by a date specified in the plan. 20

Coordination of a Review of Team Care Arrangements When coordinating a review of TCAs the practitioner must: a.explain the steps involved in the review to the patient and the patient's carer; b.record the patient's agreement to the review of the TCAs or plan; c.consult with at least two health or care providers to review all the matters set out in the relevant plan; d.make any required amendments to the patient's plan; e.offer a copy of the amended document to the patient and the patient's carer; f.provide for further review of the amended plan by a date specified in the plan; g.give copies of the relevant parts of the amended plan to the collaborating providers; and h.add a copy of the amended document to the patient's records. 21

Claiming periods A rebate will not be paid within twelve months of a previous claim for item 721 A rebate will not be paid within twelve months of a previous claim for item 723 A rebate will not be paid within three months of a claim for items 729, 731 or 732 Exceptional circumstances exist for a patient if there has been a significant change in the patient's clinical condition or care requirements that necessitates the performance of the service for the patient. 22

Assistance in completing the CDMP A practice nurse, Aboriginal health worker or other health professional may assist a GP with these items. However, the GP must meet all regulatory requirements, review and confirm all assessments and see the patient. The assistance may be provided via: patient assessment identification of patient needs making arrangements for services 23

Related allied health services Patients being managed under the chronic disease management items may be eligible for: individual allied health services (items to 10970); and/or group allied health services (items to

Further information Advice on these items and further guidance is available at: Department of Human Services provider inquiry line on telephone