"REMOTE HEALTH ATLAS Section HEALTH PROGRAMS CHRONIC DISEASE MANAGEMENT"
REMOTE HEALTH ATLAS – Section 12: HEALTH PROGRAMS CHRONIC DISEASE MANAGEMENT PLANS CHRONIC DISEASE MANAGEMENT PLANS 1. General Information The Preventable Chronic Disease Strategy has been developed to collectively address five chronic diseases: type 2 diabetes; hypertension; heart disease; kidney disease; and chronic airways disease. These diseases are indisputably important to the whole NT population and related to each other through their underlying causes. “Health care for people with chronic diseases is a mix of patient - and provider - initiated self care steps that need to be maintained over the patient's lifetime. The challenge is to create systems that support self care, link community health services with hospital services and link medical care with a public health approach.” NT Preventable Chronic Disease Strategy (PCDS) – Overview and Framework. 1999. The Chronic Disease Management Plan (CDMP) Form was developed to assist staff in providing a standard approach to the care and management of chronic disease clients for health staff practicing in a remote health care setting. The CDMP needs to be developed with the client to help promote health and wellbeing; to identify risk factors; personalise the issues that pose greatest concern to the individual and to develop goals that are meaningful. 2. Definitions Chronic Disease Management Plan: Also known as the Chronic Disease Care Plan, or Preventable Chronic Disease Care Plan. The abbreviation CDMP is utilized by Medicare Australia. SNAPE: An acronym for PCD risk factors identified for brief intervention - S = Smoking, N = Nutrition, A = Alcohol/Substance Abuse, P = Physical Activity, E = Emotional well being. 3. Responsibilities 3.1 All Clinical Health Staff Utilise the CDMP form to record chronic disease management of clients Be aware of and use the 4 Step Guide to Brief Intervention at time of consultation as required Provide ongoing health care to clients according to Chronic Disease Management Guidelines Utilise recall systems (Primary Care Information Systems (PCIS) or paper based) Promote and participate in team management of clients with Chronic Disease Maintain the client list on the PCIS where implemented or Medical Records Register, allowing for accurate population data Be aware of and attend the Pathways PCD and Women’s/Men’s Health modules as appropriate 3.2 Medical Officer Utilise the Chronic Disease Management Plan Form Completion of ‘Routine Clinical Examination by DMO / GP’ section of the form Provide review of clients with chronic disease as required Utilise CDR and PCIS computer systems where established Make Medicare claims where indicated Developed by: Professional Practice Group & PCD Program Page 1 Reviewed: December 2007 Endorsed by: Program Manager PCD Program & Best Practice Group Release Date: March 2006 Next Review: December 2008 REMOTE HEALTH ATLAS – Section 12: HEALTH PROGRAMS CHRONIC DISEASE MANAGEMENT PLANS 3.3 Preventable Chronic Disease Team Provide support and guidance with Chronic Disease Management including CDR and PCIS Coordinate the regular review of Chronic Disease Management standards Provide periodical review of recall systems (PCIS or paper based) Provide ongoing review of Chronic Disease Management Plan Form Promote attendance of the Pathways PCD and Women’s and Men’s Health modules as appropriate 3.3 Nursing Coordinator Provide on-site review of recall systems (PCIS or paper based) Provide support and guidance with Chronic Disease Management Promote attendance of the Pathways PCD and Women’s/Men’s Health modules as appropriate 3.4 Medicare Team Update PCIS or the Medical Records Register as necessary Provide support and advise re: Medicare claims Oversee Medicare claims Compile and disseminate data back to the Health Centres/DMOs regarding Medicare claims made for Chronic Disease Management 3.5 Data Coordinator Maintain community Medical Records Register Generate and disseminate PCIS reports as required 4. Procedure Remote Health Staff are required to use the CDMP form for clients with an identified chronic disease. Alternative forms should not be used. Similarly, equivalent management standards are detailed in PCIS where this has replaced paper based medical records. 4.1 Using the Chronic Disease Management Plan Form (See also Guidelines for using CDMP Form) The CDMP form provides a standard format for documenting information and a prompt for follow up care regarding the management of the client with an identified chronic disease over a one year period. A CDMP should be reviewed annually and follow up care provided every three months. The Chronic Disease Management Plan form is self-explanatory; the expectation is that all sections of the form are to be completed. It is acknowledged that completion of the form may occur over several visits. A useful aid when performing a CDMP is the Preventable Chronic Disease Routine Recall Schedule. This tool provides the routine recall intervals for follow up items for various chronic diseases according to CARPA guidelines. Any member of the clinical team can initiate the use of a CDMP. Clients having test results returned prior to the DMO / GP visit is a better utilisation of “doctor time” in the health centre. The completion of the “Routine Clinical Examination by DMO / GP” section can only be carried out by a Medical Officer and only then can a Medicare claim be made for the CDMP. Subsequent to completion of the initial CDMP, a Medicare claim can be made for a service related to the CDMP provided by a RAN or AHW and for a DMO CDMP review. Further information regarding Medicare claimable conditions are explained in 4.3 Medicare Claims, however it should be noted that for some Medicare Items it may not be possible to Developed by: Professional Practice Group & PCD Program Page 2 Reviewed: December 2007 Endorsed by: Program Manager PCD Program & Best Practice Group Release Date: March 2006 Next Review: December 2008 REMOTE HEALTH ATLAS – Section 12: HEALTH PROGRAMS CHRONIC DISEASE MANAGEMENT PLANS make a claim for each presentation of the client due to the absence of a Medical Officer. Whilst medical claims are important, the opportunity to review the client when they present and the management of their chronic disease, is the priority. Clients with a chronic disease also require a Women’s/Men’s Health Check form to be attached to the Chronic Disease Management Plan. These forms are available as a detachable portion of the Adult Health Check Form. Clients may find it difficult to have a CDMP, including the Women’s/Men’s Health Check completed during a single consultation. To provide a comprehensive service, clinical staff should be aware that a CDMP may be completed over the course of several consultations. Chronic Disease Management standards are detailed in PCIS and once the appropriate information is entered, PCIS will prompt clinicians regarding management for a client with a Chronic Disease. PCIS documentation requirements are detailed in the PCIS User Reference Manual (PCD Care Plan Management Customisation). 4.2 Recall Paper based: planning ongoing care for clients is to be documented on the CDMP and on the recall system. The recall system provides a reminder system for follow up; it does not provide detailed information but a brief description of follow-up care. The Chronic Disease Management Plan Form and or the progress notes are the correct locations to record detailed information. NB: Duplication of information is not required. Review of the CDMP refers to Part 4 of the form. Review of the client is part of follow up care and the recall system will provide the reminder system as to when the review is due. Any member of the health care team can complete this section of the form. It is only if a Medicare claim is to be made that a medical officer must complete this section. PCIS replaces the paper-based recall system and provides the recall function. 4.3 Medicare Claims Medicare claims may be made using PCIS or CDR program where a list of claimable items is generated and attached to a Medicare claim form. Alternatively, in locations where CDR or PCIS is not utilised; DMOs transcribe client details directly on to the Medicare claim form. Medicare Claim forms are then submitted to Medicare. 4.3.1 Item 721 – Care Plan by GP Only Any member of the Health Team can initiate a CDMP however to attract a Medicare benefit, the “Routine Clinical Examination by DMP or GP” section, can only be completed by a Medical Officer. There is a minimum period of 12 months between Item 721 claims for the individual client. 4.3.2 Item 723 – Care Plan By Team Utilizing the CDMP form the Health Team can make a Medicare claim for as a Care Plan developed by the Health Team. This can be done in conjunction with Item 721 and may be claimed simultaneously. The Health Team may consist of any combination of three Health Professional positions eg. RAN, AHW, Allied Health Professional or Medical Officer however it is compulsory that one team member is a Medical Officer. There must be a minimum period of 12 months between Item 723 claims for the individual client. 4.3.3 Item 725 – Review of GP Care Plan A review of the client CDMP refers to Part 4 of the form. This must be undertaken by a Medical Officer to qualify for a Medicare claim and must have an interval between either Items 721 or 725 of no less than 3 months. Developed by: Professional Practice Group & PCD Program Page 3 Reviewed: December 2007 Endorsed by: Program Manager PCD Program & Best Practice Group Release Date: March 2006 Next Review: December 2008 REMOTE HEALTH ATLAS – Section 12: HEALTH PROGRAMS CHRONIC DISEASE MANAGEMENT PLANS 4.3.4 Item 727 – Review of Team Care Plan A review of the client CDMP refers to Part 4 of the CDMP form. The Health Team may consist of any combination of three Health Professional positions eg. RAN, AHW, Allied Health Professional or Medical Officer however it is compulsory that one team member is a Medical Officer and must have an interval between either Items 723 or 727 of no less than 3 months. 4.3.5 Item 10997 – RAN & AHW Care Plan Service This item relates to a service provided to a client with a chronic disease by a RAN or AHW on behalf of and under the supervision of a medical practitioner. The client is required to have a CDMP, Team Care Arrangements or Multidisciplinary Care Plan in place and the service needs to be consistent with these, eg blood collection for CDMP review. Item 10997 may be claimed to a maximum of 5 services per client in a calendar year. 5. Forms Chronic Disease Management Plan (HX 63), available from stores Adult Health Check, including Women’s Health Check and Men’s Health Check (HX 68), available from stores 6. References and Supporting Documents Related Atlas Items: Adult Health Checks Client Recall Systems Diabetes Association Medical Records Register Medicare Items Provided by RANs & AHWs Pathways Overview Preventable Chronic Disease Program Womens & Mens Health Checks CARPA Standard Treatment Manual, 4th Ed. Guidelines for using CDMP form Medicare Australia PCIS User Reference Manual (PCD Care Plan Management Customisation) Preventable Chronic Disease Routine Recall Schedule Primary Care Information System website Step Guide to Brief Intervention – SNAPE NT Preventable Chronic Disease Strategy Developed by: Professional Practice Group & PCD Program Page 4 Reviewed: December 2007 Endorsed by: Program Manager PCD Program & Best Practice Group Release Date: March 2006 Next Review: December 2008