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. 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

3. 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 $206.75 722 (Private) $175.75 (85%) Contribute 726 $41.65 728 (Public) $41.65 730 $41.65 Review 724 $103.40 724 (review item 722) $41.65 730 $41.65

4. The New World GP 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

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 requiring ongoing 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