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 $133.65
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 $105.90
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.
3. Review of GPMP and TCA
- As of 1 May 2010 items 725 and 727 have combined into item 732. Item 732 retains ALL of the requirements of the former items and has the same Medicare benefit.
- An item 732 can be billed twice on the same day of a Review of a GPMP and a Review of a TCA were provided to the patient.
Important Notice for Allied Health Professional Services (Source: Department of Health and Ageing''s website http://www.health.gov.au/epc )
- It is NOT appropriate for allied health professionals to provide part-completed referral forms to GPs for signature, or pre-empt the GP's decision about the services required by the patient.
- The need for allied health services must be identified by the patient's usual GP. It is up to the GP to determine that the patient has a clinical need to for allied health services and to determine the type and number of services required by the patient.
- All CDM items should be provided by the patient’s usual GP.
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
| Overview CDM Items & Resource Kits - Checklists |
Downloads |
| Chronic Disease Management (CDM) Medicare Items Questions and Answers |
click here |
| Summary new changes to the Primary Health Care Items from 1 May 2010 |
PDF (235KB) |
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CDM Items Information Booklet for GPs |
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CDM Items Checklist |
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Mastering MBS Items and Diabetes SIP (Service Incentive Payments) |
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| GPMP/TCA Tracking Sheet |
Excel (29KB) |
| Prevention Item Number Utilisation Spreadsheet |
Excel (136KB) |
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| Patient Brochure on CDM MBS Items |
Downloads |
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Patient Brochure GP Management Plans and Team Care Arrangements |
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| Clinical Guidelines & RACGP Resources |
Downloads |
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RACGP Diabetes Management in General Practice (15th Edition) 2009/10 |
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RACGP Goals for Optimum Diabetes Management Reference Card |
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| RACGP Resource Templates Disease Specific Templates GPMP & TCA |
click here |
National Health Foundation Reducing Risk in Heart Disease 2007 A Guidelines for preventing cardiovascular events in people with coronary heart disease (updated 2008) Managing Coronary Heart Disease |
click here
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National Heart Foundation Reducing Risk in Heart Disease 2007 A summary guide for preventing cardiovascular events in people with coronary heart disease (updated 2008) Managing Coronary Heart Disease |
click here
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| Guidelines for the assessment of absolute cardiovascular disease risk Absolute Risk |
click here |
| Absolute risk calculator Absolute Risk |
click here |
Guide to management of hypertension 2008 (updated September 2009) Managing Blood Pressure and Lipids |
click here |
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| SDGP Practice Posters and Flyers |
Downloads |
| General Health Assessments |
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| Comprehensive Medical Assessments (Residential Aged Care Facilities) |
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| 75+ Health Assessment |
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| Type 2 Diabetes Risk Evaluation |
PDF (90KB) |
| 45 year old health check |
PDF (101KB) |
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| Useful Resources from Other Divisions of General Practice |
Downloads |
| Free Online Video Modules - Best Practice & Medical Director Online Video Training |
click here |
| Medical Director - Clean Up Your Act (North East Valley DGP) |
PDF (1063KB) |
| MBS EPC, Chronic Disease Management Items for GPs (Western Melbourne DGP) |
PDF (48KB) |
| Useful Guides EPC & CDM Resources (Balarat & District DGP) |
click here |
| CDM Templates and Resources (North East Valley DGP) |
click here |
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Australian Primary Care Collaboratives |
click here |
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.
GP referral forms and electronic templates for the CDM Items are available here.
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