Chronic Disease Management Items and other Initiatives

GP Management Plan & Team Care Arrangement Overview

Relevant Resources for GPs

Electronic GP Referral Templates

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 $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.