REMOTE HEALTH ATLAS Section HEALTH PROGRAMS CHRONIC DISEASE MANAGEMENT by rockandrolldreams

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									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

								
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