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.
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 |
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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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| 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 |
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| Useful Resources from Other Divisions of General Practice |
Downloads |
| 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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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) |
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GP Cover Letter Team Care Arrangement to Allied Health Professionals |
MD Template (RTF 6KB) |
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Medicare Australia Allied Health Referral Form |
MD Template (RTF 212 KB) |
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| GP Management Plan and Review Templates |
Downloads |
Downloads |
| GP Preparation (721 and 723) GP Management Plan and Team Care Arrangement |
MD Template (RTF 24KB) |
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GP Preparation of a GP Management Plan for Diabetic Patients |
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| GP Review (725 and 727) GP Management Plan and Team Care Arrangement |
MD Template (RTF 20KB) |
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| 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 |
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| Hospital Referral Templates |
Downloads |
Downloads |
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Referral Cardiac Rehab, Diabetes Education Centre, Heart/Lung Sutherland Hospital |
MD Template (RTF 24KB) |
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High Risk Foot Clinic - St George/Sutherland Hospitals (Central Network) GP Referral to Central Hospitals Network Multidisciplinary |
CLICK HERE |
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Access and Referral Intake Form - St George/Sutherland Hospitals (Central Network) GP Referral - Common Referral Form |
CLICK HERE |
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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.
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