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Chronic Disease Management Items and other Initiatives

 GP Management Plan & Team Care Arrangement Overview
   
 Relevant Resources for GPs
 
 Electronic GP Referral Templates

 Practice Posters/Flyers

 Important Notice for Allied Health Professionals   Important Notice ! 

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;

  1. GP Management Plan – GP only service
  2. 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)

CDM Items Information Booklet for GPs

CDM Items Checklist

Mastering MBS Items and Diabetes SIP (Service Incentive Payments)                               
GPMP/TCA Tracking Sheet Excel (29KB)
Prevention Item Number Utilisation Spreadsheet Excel (136KB)
   
Patient Brochure on CDM MBS Items Downloads
Patient Brochure GP Management Plans and Team Care Arrangements
   
Clinical Guidelines & RACGP Resources Downloads  
RACGP Diabetes Management in General Practice (15th Edition) 2009/10   
RACGP Goals for Optimum Diabetes Management Reference Card
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

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

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
 
SDGP Practice Posters and Flyers  Downloads
General Health Assessments
Comprehensive Medical Assessments (Residential Aged Care Facilities) 
75+ Health Assessment 
Type 2 Diabetes Risk Evaluation PDF (90KB)
45 year old health check PDF (101KB)
   
Useful Resources from Other Divisions of General Practice Downloads
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

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. 


Electronic Referral Templates - Medical Director (MD) and Word versions 

Allied Health Templates for GPs Downloads Downloads
Refusal Letter to Allied Health Professionals initiating Team Care Arrangement MD Template (RTF 15KB)
"Reverse Referral" Allied Health Professionals initiating Team Care Arrangement or
providing part-completed referral forms to GPs for signature, or pre-empt the GP's decision
MD Template (RTF 4KB)

GP Cover Letter Team Care Arrangement to Allied Health Professionals

MD Template (RTF 6KB)
Medicare Australia Allied Health Referral Form
MD Template (RTF 212 KB)  
     
GP Management Plan and Review Templates Downloads  Downloads 
GP Preparation (721 and 723) GP Management Plan and Team Care Arrangement   MD Template (RTF 24KB)
GP Preparation of a GP Management Plan for Diabetic Patients
GP Review (725 and 727) GP Management Plan and Team Care Arrangement MD Template (RTF 20KB) 
Generic Referral MD Template (Monash Division of General Practice)    MD Template (RTF 18KB) WORD (37KB) 
RACGP Disease Specific Templates Management Plans/Team Care Arrangements  CLICK HERE  
     
Hospital Referral Templates Downloads  Downloads 

Referral Cardiac Rehab, Diabetes Education Centre, Heart/Lung Sutherland Hospital  

MD Template (RTF 24KB)

High Risk Foot Clinic - St George/Sutherland Hospitals (Central Network)
GP Referral to Central Hospitals Network Multidisciplinary  

CLICK HERE
 
Access and Referral Intake Form - St George/Sutherland Hospitals 
(Central Network) GP Referral - Common Referral Form

CLICK HERE
 

Note: The cover letter can assist GPs in communicating with potential members for Team Care Arrangement (i.e. Allied Health Professionals).  

Electronic MD 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.

Instruction Notes for RTF Medical Director (MD) Templates    CLICK HERE TO DOWNLOAD (PDF 84KB) 
Instruction Notes for RTF Best Practice (BP) Templates   CLICK HERE TO DOWNLOAD (PDF 66KB)