Chronic Disease Management Items and other Initiatives
CDM ITEMS - GP MANAGEMENT PLANS & TEAM CARE ARRANGEMENTS
The Medicare Benefits Schedule (MBS) has developed service items to assist GPs to manage the health care of patients with chronic medical conditions, including patients needing multidisciplinary care. There are two service items;
- GP Management Plan – GP only service
- Team Care Arrangement – multidisciplinary care planning
GP Management Plan Item (721)
Item Information
- GP service item for the preparation of a management plan for patients with a chronic or terminal condition
- Includes patient assessment and identification of needs and problems
- Establishment of management goals, services required and actions to be taken
- Provision must be made for review of the plan
- GPs can be assisted by practice nurses in providing the service
- Length of plan is 2 years, with 6 monthly reviews
- Rebate $124.95
Who is eligible
- Patients with chronic or terminal medical conditions who will benefit from a structured approach to management of their care needs.
- Patients with a chronic medical condition that has been present (or is likely to be present) for 6 months or more
Team Care Arrangements (723)
Item Information
- GP service to coordinate the preparation of a management plan for patients with a chronic or terminal medical condition who also require ongoing care from a multidisciplinary team
- Team must include a minimum of 3 members (GP/Practice Nurse plus 2 others)
- Must have a GP Management Plan in place
- Involves collaborating with participating providers (Allied Health Providers) for required treatments or services and documenting in the plan
- GPs can be assisted by practice nurses in providing the service
- Length of plan is 2 years, with 6 monthly reviews
- Rebate $98.95
Who is eligible
- Patients with a chronic or terminal medical condition AND who require ongoing care from a multidisciplinary team of their GP and at least 2 other health or care providers.
- Recommended that the patient has a GP Management Plan in place.
The Division provides education and training to GPs, Practice Nurses and Practice Staff in the preparation and review of the Medicare CDM Items. Training is provided through practice visits, workshops and CPD events.
CDM ITEMS GP MANAGEMENT PLAN & TEAM CARE ARRANGEMENT AND OTHER RESOURCES FOR GPs
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Booklet - CDM Items Information Booklet for GPs |
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CDM Items Checklist |
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Allied Health Referral Form Medicare Australia (Word) |
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Patient Brochure GP Management Plansand Team Care Arrangements |
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GP Preparation of GP Management Plan (721) and Team Care Arrangement (723) |
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| Generic Referral Template Word Document (Monash Division of General Practice) |
WORD (37KB) |
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GP Review of both GP Management Plan and Team Care Arrangement |
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GP Preparation of a GP Management Plan for Diabetic Patients |
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GP Referral Form to Cardiac Rehab, Diabetes Education Centre,
Heart and Lung Team at Sutherland Hospital |
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Mastering MBS Items and Diabetes SIP (Service Incentive Payments) |
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RACGP - Diabetes Management in General Practice (Clinical Management Guidelines) 2007/08 |
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RACGP - Goals for Optimum Diabetes Management Reference Card |
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Note: The CDM booklet is compiled by the Division using information provided by the Australian Government Department of Health and Ageing New Chronic Disease Management Items.
Electronic Templates for Medical Director (Items 721, 723, 725 and 727 including Hospital Templates)
Note: The cover letter can assist GPs in communicating with potential members for Team Care Arrangement (i.e. Allied Health Professionals).
Electronic Templates - Downloading and Importing MD templates from the website. What to do with an "RTF" link.
DO NOT DOUBLE CLICK ON THE 'RTF' LINK TO OPEN IT - THIS WOULD OPEN THE TEMPLATE IN WORD. The end result of this is that you would lose the Medical Director fields that 'populate' the template.
- Right click on link and select Save Target As...
- Select a location on hard drive (which you can find later) and save.
- Open Medical Director and then Letter Writer.
- File menu > Select Modify Template > Select Blank template.
- File > Select Import - locate downloaded file and click on Open.
- File > Select Save as template. Type in appropriate name and click on Save. Once saved you can access the template with a patient record open in Medical Director. Open LetterWriter- File/New and then select the appropriate template.
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