Transcript Treasurer’s Report Dr Stephen Barry

General Practice Gold Coast
Chronic Disease Management from
a Whole of Practice Perspective
Objectives
 Increase awareness of Chronic Disease Management
 Provide information on CDM MBS item numbers
 Increase awareness of how to implement CDM into
General Practice
 Opportunity to network with peers
Chronic Disease Management
 Approximately 70 per cent of the total burden of disease in
Australia is attributable to 6 disease groups, all of which
have the potential to be either prevented or managed in
settings other than hospital care
 The Australian Government responded to the growing
burden of chronic disease with a number of initiatives to
prevent and manage chronic disease within the primary care
setting
Chronic Disease Framework
 Chronic Disease Management (CDM)
 In 2005 the GP Enhanced Primary Care (EPC) care planning
items/terminology became obsolete and were removed from
the MBS these were replaced by the Chronic Disease
Management (CDM) items (721-731). The term 'EPC plan' is
now obsolete.
 There are no changes to the eligibility requirements for the
CDM items, including the allied health services for people
with chronic disease. This is simply a change to terminology
to bring it up to date.
 The CDM framework is supported by incentives designed to
encourage best practice management of CD in primary care
 Practice Incentives Program (PIP)
 The aim of the PIP is to provide incentives that
encourage general practices to deliver quality care to
patients
 Practices are required to be accredited or working
towards accreditation with the RACGP Standards for
General Practices
 Website: www.racgp.org.au/standards
 Service Incentive Payments (SIP)
 These payments have been put in place to encourage
evidence-based, best practice systems of care for
patients with diabetes and asthma and for prevention of
disease through immunisation and Pap tests
 General practices must be participating in the PIP to be
eligible to receive SIP payments
 Claiming of SIP item numbers through Medicare
triggers additional ‘payments for quality’ (the
application of best practice clinical guidelines)
CDM and the MBS
 The MBS provides incentives for GPs to provide:
proactive, coordinated care for their patients through
the CDM items
 There are now 5 CDM MBS items that provide rebates
for GPs to manage chronic disease by
1.
2.
3.
4.
Preparation of GP management plans (GPMPs)
Item 721
Coordination of team care arrangements (TCAs)
Item 723
Review of GPMPs and TCAs. Item 732
Contribution to and review of multidisciplinary care
plans (MCPs). Items 729 and 731
Eligibility
 CDM service is for a patient who has at least one
medical condition that:
 (a) has been (or is likely to be) present for at least six
months; or
 (b) is terminal.
1. Preparation of a GP
Management Plan. Item 721
 Comprehensive care planning underpins the effective
delivery of CDM.
 The GPGC provides a vehicle to enhance concordance
between the GP and patient, empowering the patient
to take responsibility for their goals and encouraging
improved self-management
 The GPMP is a mechanism designed to support the GP
and practice staff in care planning and disease
management processes
Steps required to implement GPMP
 Explain
 The steps involved to the patient (and the patient’s carer
if appropriate)
 Develop
 And document the GPMP
 Obtain
 And document the patient’s agreement
 Offer
 A copy of the plan to the patient and the patient’s carer,
if appropriate
 Record
 The plan in the patient’s medical record
GPMP
A GP Management Plan document should include:
1. The patient’s conditions, problems and health care
needs
2. Treatment targets and goals as agreed with the
patient
3. Actions to be taken by the patient such as therapy
adherence and lifestyle changes
4. Treatment and services the patient needs and
arrangements for these
5. A plan to review the GPMP by a date specified
2. Coordination of Team Care
Arrangements (TCA) Item 723
 Optimal care for patients with complex chronic
disease(s) needs often involves a coordinated team of
health care providers
 A TCA is a tool within the MBS designed to support
coordinated care with a collaborating team of
providers
 Prior to the TCA, patients should have a GPMP
developed
 Development of the TCA involves identification of
appropriate team care providers, referrals and
communication with the care providers
When coordinationg the development of a TCA
the GP must:
 Consult with at least two collaborating providers
 Prepare a document (GPMP) that describes
1. Treatment and service goals for the patient
2. Treatment and services that collaborating providers
will provide to the patient
3. Actions to be taken by the patient
4. Arrangements to review by a date specified
 Explain the steps involved to the patient and the

patient’s carer, if appropriate
Discuss with the collaborating providers who will
contribute to the TCA and provide treatment and
services under those arrangements
Cont..
 Record the patient’s agreement to the development of
TCA
 Give copies of the relevant parts of the document to
collaborating providers
 Offer a copy to the patient and the patient’s carer, if
appropriate
 Add a copy of the document to the patient’s medical
records
The PN may assist with the GPMP/TCA preparation by
 Providing relevant and comprehensive information for
the documents
 Discussing the GPMP/TCA process with patients,
facilitating the development of patient centred
treatment goals
 Educating patients on self management skills
 Coordinating communications with the care team
3. Review of a GPMP or TCA
Item 732
 A GPMP or TCA review is designed to support the
continuity of care and continued focus on best practice
care for patients with CD
 GPMPs and TCAs can be reviewed by a GP from the same
practice or, if the patient changes practices, by their new
GP
 The process for reviewing a GPMP or TCA document with a
patient includes:
 Review patient self-management goals
 Discuss barriers to the achievement of goals
 Discuss potential solutions to these barriers
 Consider additional plans for support such as referral to AHP
 Reset goals for the next 3 to 6 months
When reviewing a GPMP, TCA or multidisciplinary care
plan the following steps are required
 Explain to the patient and the patient’s carer the steps







involved in the review
Record the patient’s agreement to the review of the plan
Review all the matters set out in the relevant plan and for
TCAs, collaborating health care providers should provide
updates on the treatment/services they provide
Make any required amendments to the patient’s plan
Offer a copy of the amended document to the patient and
the carer and give copies of the amended plan to the
collaborating providers
Set a date for next review of the plan
Add a copy of the amended document to the patient’s
records and
Provide for further review of the amended plan by a date
specified in the plan
4. i) Contribution to or review of a Multidisciplinary
Care Plan. Item 729 and 731
 Item 729 is available to patients in the community,
hospital discharge patients (private and public) and
patients not cared for in a residential aged care facility
 Item 731 is available only to patients who are residents
of aged care facilities
 A multidisciplinary care plan is a written plan that is
prepared for a patient by


A collaborating provider (other than a medical practitioner)
in consultation with two other providers, each of whom
provides a different service to the patient
Describes treatment and services to be provided to the patient
by the collaborating providers
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 the patient’s medical records, any advice provided
General Practice Team
Roles and Responsibilities
 Development of a team approach to patient centred
care delivered through general practice will ensure
maximum efficiency and effective CDM
 The practice team needs clear communication and
direction with regard to roles and responsibilities in
implementing a systematic approach to CDM
Teamwork
Leadership
Organisation
& Systems
Collaborative &
Transdisciplinary
Info Mgt & Training &
Development
Tech
Developing relationships
Community Services
Specialist Consultant
Diabetes Educator
ACAT Assessment
Respite
Dietitian
Pharmacist
GP/PN
Occupational Therapist
Meals on Wheels
Patient
Veterans Affairs
Optometrist
Speech Therapist
Exercise Physiologist
GP team
Annual Cycle of Care
Personalised Education
Chiropractor
Podiatrist
Chiropodist
Patient self
management
Osteopath
Resources
Aboriginal Health Worker
Mental Health Worker
Physiotherapist
Audiologist
Psychologist
21
Resources
State, Fedral and
Community
Specialist
Providers
Primary Care
Practice Team
Patient/
Client
Carers
Allied
Health
Providers
GP team Roles and Responsibilities
 General practice must be well organised to implement
effective chronic care.
 This requires teamwork and practice systems to
support team care and the use of evidence-based
guidelines
 Effective CDM teamwork in general practice
encompasses GPs, clinical and non-clinical staff each
with clearly defined roles and opportunities to provide
feedback and input into how the system is
implemented and CD is managed
General Practitioner
 GPs remain the focal point for the management of patients with





CD and are responsible for encouraging a focus on systematic
approaches for proactive management of patient care
Understand best practice and current guidelines for
management of chronic disease
Provide leadership within the practice to build a patient centred
focus
Make clinical decisions with regard to targets, treatments,
services and referrals
Provide support for PN including training and time for
collaboration, time to develop, clean and maintain databases
Obtain patient consent to share medical information required
for CDM items
Practice Manager
 The practice manager’s role underpins the capacity and




capability of practices and staff to effectively manage
patients with chronic disease
Manage the practice environment including PIP
accreditation processes, clinical management software,
health records management and occpational health and
safety
Manage the financial aspects and billing practices, improve
efficiency, contracts and optimising the use of professional
resources
Manage, coach and develop practice staff, build the
practice base and the capacity to adapt to change
Identify, integrate and mobilise CDM programs and
community resources
Practice Nurse
 Practice nurses play an important role in the
management of patients with CD and in the
overall organisation required to support CDM
 Provide CDM support through clinical nursing
services, patient assessment, planning an
coordinating care for patients, preparation of
GPMPs, diagnostic services and recommendations
for therapy or referrals
 Run disease specific clinics and preventive health
programs including patient self-management
education
 Develop care networks and systematic approaches
to patient identification, registers, recalls and
reminders, database cleansing
 Integrate service delivery, network with other
services and provide feedback and connectivity
between the services, patients and GP
 Develop and maintain practice and patient
educational resources and health promotion
CDM Implementation in Practice
The Chronic Disease Management Process
 Effective and efficient management of patients in
primary care requires the implementation and
maintenance of systematic approaches utilising the
practice clinical software as the primary platform
Implementation of a systematic approach to
CDM should include the following steps:
 Practice Audit
 Identify care patterns in the practice and information
gaps
 Patient Disease Register
 Develop a disease register which requires GPs and staff
to utilise the functionality of the software
 Patient Identification
 Search the electronic system to identify patients who
meet recall eligibility criteria
Cont...
 Recall and Reminder Systems
 Develop a system for recalling patients and appointment
reminders
 Patient Review and Assessment
 Review patient medical history, diagnoses, medications
and undertake a patient assessment
 Documentation and Care Planning
 Coordinate GPMPs. TCAs, multidisciplinaty care plans,
plan for reviews, and communicate with the provider
team
Diabetes Care within the MBS Framework
Type 2 Diabetes Management and Best Practice within the MBS CDM Framework
1st Visit – CDM
Preparation of a GPMP – Item 721
Consider Group
Allied Health Referrals
Coordination of TCA – Item 723
Consider Individual
Allied Health Referrals
Dietician
Individual Services:
Item
10997
3rd Visit – CDM
Credentialed Diabetes Educator
Exercise Physiologist
Item
10997
2nd Visit – CDM
Group Services:
Credentialed Diabetes Educator
Review GPMP and TCA Coordination – Item 732
Utilise Item 732 Twice in this Visit*
Dietician
Podiatrist
Dentist
Item
10997
4 Visit
Diabetes
Incentives &
CDM:
Includes a full
explanation of
the Diabetes
Cycle of Care
Level A, B, C or D Consult
Mid-Year Diabetes Review
Item
10997
5th Visit - CDM
Review GPMP and TCA Coordination – Item 732
Utilise Item 732 Twice in this Visit*
Item
10997
6th Visit
Review Reports from
Credentialed Diabetes Educator
Dietician
Level B, C or D Consult
Complete Annual Diabetes Cycle of Care Item 2517, 2521 or 2525
Podiatrist
Dentist
Chronic Disease Management
So now you know what to do, what to bill, and
whether CDM is important to your workplace
But lets talk about actually introducing CDM into
your workplace
Chronic Disease Management
Chronic Disease Management
Finding time, setting up documentation, making
connections with your CDM team and discussing
ways of introduction with your team
Chronic Disease Management
Chronic Disease Management
Every workplace will have a different system,
different paperwork and different team profiles.
We all have the same common goal to achieve
optimum health benefits for our patients
Chronic Disease Management
Chronic Disease Management
Make time to connect with local allied health.
Have templates available
Have all team members understanding the purpose
of plan and understand booking system
Chronic Disease Management
Allocate time for plans
Assess patients eligibility
Have systems in place to check all components are
completed
Chronic Disease Management




Care Plan Hints
Care Plans, also known as GP Management Plans previously known as
Enhanced Primary Care
Provided for patients with chronic disease to assist self management
All Patients, check:










Contact details including address & phone
A&TSI status
Past Medical History, including all relevant History is ticked in summary box
Family History
Social History
Smoking
Alcohol status
Weight
Blood Pressure
Relevant Pathology – Hba1c, microalbumin, lipids, egfr – when were they
last done?
Chronic Disease Management
 Asses what patient’s are eligible for:
 New plan, 721,723 (can be billed second yearly so check
pracsoft billing/contact Medicare
 Or review, 732 (related to a 721) and a 732 related to a 723
(eligible 12 weeks after last care plan billing but routinely
done at 6 months)
 Therefore if looking at billing cycle could have one
billing 721 & 723 followed by 732 in a two year process
if timing correct.
Chronic Disease Management
 Patients needing a Team Care Arrangement will
require two providers of care other than those
provided by a GP. If using new provider in addition to
sending Team Care Agreement letter. Call provider to
check their acceptance in plan and advise them they
will need to send our agreement back.
 Providers of care must relate to condition seeking need
for and provided different services for patient
Chronic Disease Management
 Examples of providers of care include but are not
limited to:
 Allied Health Professionals – Physio, Podiatry, Exercise
Physiologist, Psychologist, Dietician, Social Worker,
Diabetes Educator.
 Private Specialists
 Hearing Clinics
 School Teacher
 All completed plans will remain in the surgery until
letters of acceptance/previous treatment letters are
returned and Medicare billed.
Chronic Disease Management
 The Nurse in collaboration with your Doctor will
establish your eligibility to have a care plan and this
will be on your medical history. A care plan may allow
access to some funding from Medicare for Allied
Health services.
Chronic Disease Management
 Assessment Booking Sheet – with appointments
including:
 What patient is booking in for
 Date
 Column for checked eligibility
 Drs name
Chronic Disease Management
 Care plan for ________________________________________
 Care plan produced on ________________________________
 Awaiting Treatment Letter from___________________________
 Awaiting Acceptance from_______________________________
 When received to bill ___________________________________
 DR__________________________________________________
 Pt Contacted for collection ________________________________
 Date collected/posted____________________________________
Chronic Disease Management
 All clinics will have unique method, individualised
plans and systems in place