Chronic Disease Management Busine by hilen

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									                          GP Management Plan
                                           Flow Chart Item 721
                                                                                            GPMP Review
  GP Management
                                                   GPMP Set up                                Item 725
       Plan                                                                                 Claimed by GP with
 Patient with chronic condition                      Item 721                                assistance of PN or
  that has been, or is likely to be               Claimed by GP with                        other
present, for at least six months or                assistance of PN or other
that is terminal. (Not necessarily                                                          Every 3-6 months, or
                                                  Every 2 years                             when clinically required
 requiring multidisciplinary care).

Identify     Contact patient by phone or send a letter
             Arrange a time to see the patient
            This can be carried out in a number of ways by a number of people:
             Opportunistically- when patients make an appointment with the practice, flag them as eligible for
               a GPMP
             Register and recall system
             The Pencs Clinical Audit Tool to generate a list of eligible patients, excluding “in-active” patients
               etc.
             General Practitioner
             Practice Nurse
             Reception/ Administration staff
             Practice Manager

Prepare        Prepare a written plan using the practice template and keep in patient file.
                For template ideas and to load into Medical Director- visit www.anedgp.com.au under templates
                and referral forms.
            This can be prepared:
             Prior to, or during the consult with the patient, book a long consult with the GP
             By the practice nurse, Allied Health Professional (AHP) or an Aboriginal Health Worker (AHW)
                with or with out the patient present.
            If preparation is done by practice nurse, AHP or an AHW it must be followed by a 10-15 minute
            consult with the patient’s normal GP to finalise and sign the plan.
            Include:
             Individualised goal setting, information and advice for the patient
             List and record information and resources handed to or discussed with patient
             The person providing the service and their contact details
             Lifestyle goals/ changes to achieve such as smoking status, nutrition, alcohol intake and
                physical activity level as well as addressing the guidelines for management of the chronic
                condition(s) the patient is diagnosed with.

Consult         Check for eligibility and existing care plan- ask patient/ check with Medicare Australia
                Discuss benefits of and cost involved in the care plan
                Assess patient
                Identify, agree to and record patient needs and relevant conditions, goals to be achieved, actions
                 planned, and the person providing the treatment/ service
             Patient signature or a record of their consent on plan and print a copy for patient
             Add a copy to the patient’s file and if a copy is required by any other health providers, patient
                 consent for information sharing must be recorded
             Discuss options for Team Care Arrangement Plan (if clinically required)
             Schedule date for review of plan in 3-6 months time
            If the patient has:
               Diabetes- complete and Annual Cycle of Care SIP and consider group referral (see over).
               Asthma- consider the Asthma Annual Cycle of Care SIP
               A mental health issue- consider GP Mental Health Care Plan
               A mental health issue and complex health care needs- they are also eligible for the GP
                  Mental Health Care Plan: Item number 2710 as well as 723 and 721

 After      Claim Item Number 721. The GP can claim the item number once all documentation is complete,
            patient consent obtained and the GP has seen the patient.
     Examples of                                            721 and 723 Guidelines
   Chronic Diseases
                                  A GPMP and a TCA can both be claimed at the same time provided the two
                                  services are delivered as per the Medicare items.
AIDS/ HIV                         The TCA does not need to be an entirely separate document to the GPMP
Arthritis-                        preventing unnecessary duplication. Provided the relevant information is
   osteoarthritis,                documented. The TCA can be included as an addition to the patient's GPMP
                                  as an extra page that includes the goals, the collaborating providers, the
   osteoporosis,                  treatment/services they have agreed to provide, patient actions and a review
   rheumatoid                     date.
   arthritis                      A separate standard consultation should not be billed with a GPMP, TCA or
Asthma                            review of either service unless it is clinically indicated that a problem must be
                                  treated immediately; or the GPMP was not the original purpose of the
Chronic Kidney                    consultation. Accounts that include both a CDM item and a consultation must
Disease                           be annotated accordingly.
COPD
Chronic Renal
Impairment                                                     721 Referral Options
Colorectal Cancer
                                   As of May 1 2007, the allied health items 81100 to 81125 allows people with
Coronary Heart                     type 2 diabetes with a GPMP to receive Medicare rebates for group services
Disease                            provided by eligible diabetes educators, exercise physiologists and dietitians,
Dementia                           on referral from a GP. These services are in addition to the five individual allied
Diabetes                           health services available to eligible patients each calendar year under items
                                   10950 to 10970.
Lung Cancer                        For more information visit the Department of Health and Ageing website at:
Mental Health                      www.health.gov.au/epc
Most cancers                                                   723 Referral Options
   (excluding BCC,                 Patients with both a GPMP and TCA in place are eligible for 5 Allied Health
   SCC of skin)                    rebated services and per calendar year. Allied Health Professionals who utilise
Multiple Sclerosis                 these rebated visits include: Aboriginal Health Worker, Audiologist,
                                   Chiropractor, Chiropodist, Diabetes Educator, Dietitian, Exercise Physiologist,
Oral Diseases                      Mental Health Worker, Occupational Therapist, Osteopath, Physiotherapist,
Palliative care                    Podiatrist, Psychologist, and Speech Pathologist.
Parkinson’s                        In a TCA referrals can be made to other professionals that are not involved in
                                   Medicare rebates these can include: Asthma Educator, Social worker, Quitline,
Disease                            Arthritis SA, Weight management, Home Medicines Review, RDNS, Helping
Prostate Cancer                    Hand, Meals On Wheels, Pharmacists (preferably for medication management
Stroke                             through a Home Medicines Review- Item 900), and the Practice Nurse (as long
                                   as they are providing a service independent to the role of the GP.)
Thyroid illness


                                                  Exclusion List
         Obesity, Smoking, Unspecified chronic pain, Pregnancy, Impaired glucose tolerance,
                      Hypercholesterolaemia, Hypertension and Syndrome X.
On their own these are not regarded as chronic conditions. A patient may have complications or co-morbidities that may
be a result of or exacerbated by such risk factors making them eligible for CDM services.



                                                                Resources
                     For resources, referral forms and templates visit www.anedgp.com.au. The Adelaide North East
                     Division has developed a number of disease specific templates for GP Management Plans and
                     Team Care Arrangements to meet the current guidelines for best management of various chronic
                     conditions such as asthma, arthritis, COPD and Diabetes as well as others.


                           Contact the Division on 8397 9000 or email anedgp@anedgp.com.au
                                To down load these charts and more visit www.anedgp.com.au
                                             Details current as at February 2009
                     Team Care Arrangement
                                           Flow Chart Item 723
      Team Care
                                            TCA Preparation                             TCA Review
     Arrangement
   Claim with or with out a GP                    Item 723                                 Item 727
       Management Plan                         Claimed by GP with                   Claimed by GP with
 Claimed by GP with assistance                  assistance of PN or other              assistance of PN or other
      For patients requiring                   Every 6 months                       Every 3-6 months, or
      multidisciplinary care                                                           when clinically required

Identify   A Team Care Arrangement allows patients with chronic conditions needing multidisciplinary
           care access to Allied Health Professionals accompanied with Medicare Rebates for these
           visits (5 visits per calendar year per patient). Identifying eligible patients can be carried out in
           a number of ways:
              During the preparation of the GP Management Plan discuss whether the patient could benefit
               from the care provided by another health professional(s) and decide what profession(s) would be
               most beneficial.
              Prior to consult; in a previous consult it may have been discussed what Health Professionals
               would be required.
              After a number of months with a GPMP in place the patient might require outside health
               professional in put into the management of their chronic disease, a TCA can be prepared at this
               point in time.

Prepare       Communicate with the identified Allied Health Professionals (AHP) via phone conversation,
               email, letter or fax regarding the individual needs of the patient goals and outcomes desired.
              Discuss reporting/ communication methods between the AHP and the GP in relation to patient
               progress.
              Confirm the bulk billing or gap arrangements that suit the patient’s needs.
           Note: to be eligible to receive the 5 allied health rebated visits the patient MUST have both a 721
           AND 723 claimed and recorded with Medicare Australia. If the claim is made via mail this can take
           up to 2 weeks to process by Medicare; delaying the closest possible AHP visit to 2 weeks after the
           claim of a 723.
            A separate document for a TCA is not necessary if there is an existing GPMP. Document the
               AHP or other health professional involved in the TCA, their name, contact details, agreement to
               participate, and the goals for their treatment and services for the patient.


Consult      Discuss AHP goals with the patient either prior to confirmation with AHP (claim a normal consult
              or if appropriate an item 721- preparation of a GP Management Plan) or following confirmation
              with AHP (in this case an item 723 can be claimed on the day of the consult with the patient).
           Note: Prior to claiming item 723 participation from all AHP must be confirmed
              Practice Nurse can be utilised to discuss option for care with patient, and investigate AHP and
               other health professionals and gain agreement to participate.
              Fill in the EPC Referral Form- indicating the number of visits allocated the AHP filling in
               separate forms for each AHP involved. Give form(s) to patient for AHP to claim for the rebate
               from Medicare. For a MD template of this referral form visit www.anedgp.com.au click on the
               Templates and Referral forms tab and follow the instructions.
              Patient signature or a record of their consent on plan and print a copy for patient
              Add a copy to the patient’s file and if a copy is required by any other health providers, patient
               consent for information sharing must be recorded
              Schedule date for review of plan in 3-6 months time
           If the patient has:
              Diabetes- complete and Annual Cycle of Care SIP if required.


 After     Claim Item Number 723. The GP can claim the item number once all documentation is complete,
           patient consent obtained, agreement from AHP to participate and the GP has seen the patient.
      Examples of                                             721 and 723 Guidelines
    Chronic Diseases
                                  A GPMP and a TCA can both be claimed at the same time provided the two
                                  services are delivered as per the Medicare items.
 AIDS/ HIV                        The TCA does not need to be an entirely separate document to the GPMP
 Arthritis-                       preventing unnecessary duplication. Provided the relevant information is
    osteoarthritis,               documented. The TCA can be included as an addition to the patient's GPMP as
                                  an extra page that includes the goals, the collaborating providers, the
    osteoporosis,                 treatment/services they have agreed to provide, patient actions and a review
    rheumatoid                    date.
    arthritis                     A separate standard consultation should not be billed with a GPMP, TCA or
 Asthma                           review of either service unless it is clinically indicated that a problem must be
                                  treated immediately; or the GPMP was not the original purpose of the
 Chronic Kidney                   consultation. Accounts that include both a CDM item and a consultation must be
 Disease                          annotated accordingly.
 COPD
 Chronic Renal
 Impairment                                                    721 Referral Options
 Colorectal Cancer
                                   As of May 1 2007, the allied health items 81100 to 81125 allows people with
 Coronary Heart                    type 2 diabetes with a GPMP to receive Medicare rebates for group services
 Disease                           provided by eligible diabetes educators, exercise physiologists and dietitians,
 Dementia                          on referral from a GP. These services are in addition to the five individual allied
 Diabetes                          health services available to eligible patients each calendar year under items
                                   10950 to 10970.
 Lung Cancer                       For more information visit the Department of Health and Ageing website at:
 Mental Health                     www.health.gov.au/epc
 Most cancers                                                  723 Referral Options
    (excluding BCC,                Patients with both a GPMP and TCA in place are eligible for 5 Allied Health
    SCC of skin)                   rebated services per calendar year. Allied Health Professionals who utilise
 Multiple Sclerosis                these rebated visits include: Aboriginal Health Worker, Audiologist,
                                   Chiropractor, Chiropodist, Diabetes Educator, Dietitian, Exercise Physiologist,
 Oral Diseases                     Mental Health Worker, Occupational Therapist, Osteopath, Physiotherapist,
 Palliative care                   Podiatrist, Psychologist, and Speech Pathologist.
 Parkinson’s                       In a TCA referrals can be made to other professionals that are not involved in
                                   Medicare rebates these can include: Asthma Educator, Social worker, Quitline,
 Disease                           Arthritis SA, Weight management, Home Medicines Review, RDNS, Helping
 Prostate Cancer                   Hand, Meals On Wheels, Pharmacists (preferably for medication management
 Stroke                            through a Home Medicines Review- Item 900), and the Practice Nurse (as long
                                   as they are providing a service independent to the role of the GP.)
 Thyroid illness


                                                  Exclusion List
         Obesity, Smoking, Unspecified chronic pain, Pregnancy, Impaired glucose tolerance,
                      Hypercholesterolaemia, Hypertension and Syndrome X.
On their own these are not regarded as chronic conditions. A patient may have complications or co-morbidities that may
be a result of or exacerbated by such risk factors making them eligible for CDM services.



                                                                Resources
                     For resources, referral forms and templates visit www.anedgp.com.au. The Adelaide North East
                     Division has developed a number of disease specific templates for GP Management Plans and
                     Team Care Arrangements to meet the current guidelines for best management of various chronic
                     conditions such as asthma, arthritis, COPD and Diabetes as well as others.


                            Contact the Division on 8397 9000 or email anedgp@anedgp.com.au
                                 To down load these charts and more visit www.anedgp.com.au
                                               Details current as at February 2009

								
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