1. Supporting nurses in primary health care www.apna.asn.au 1300 303 184 admin@apna.asn.au

2. Person Centred Care Planning Ros Rolleston RN Primary Health Care Nurse & Educator rwr@australiamail.com December 2014

3. Learning Objectives  Discuss practice funding  Describe Medicare eligibility & requirements  Develop person centred approach to chronic disease management  Improve multidisciplinary team communication

4. Practice Funding  Practice Nurse PIP  $25000:1000 SWPE for RN working 12.6hrs/wk  Rural and AMS loading  Diabetes PIP  Asthma PIP

5. CDM Rebates  GPMP/TCA – 721/723  $258.55  Review GPMP/TCA – 732x2  $144.10  Contribution to RACF care plan – 731  $70.40  Contribution to another’s care plan – 729  $70.40  Monitoring & support by GPN – 10997  $12 http://www9.health.gov.au/mbs/search.cfm?q=721&sopt=S

6. GP Time Based MBS Rebates  Asthma Cycle of Care, 2546/52/58  $37.05 – $105.55  Diabetes Cycle of Care, 2517/21/25  $37.05 – $105.55  Mental Health Care Plan, 2700 series  $71.70 – $134.10  GP consultation item numbers no longer claimable on the same day as CDM services http://www9.health.gov.au/mbs/search.cfm?q=2700&sopt=S

7. MBS Eligibility  Chronic illness  6m  Clinical decision of the GP  Mental health  Reduced capacity to self care  Intellectual or physical disabilities including kids  Obesity,  BP,  lipids,  glucose,  LFTs  RACF, hospital discharge http://www9.health.gov.au/mbs/fullDisplay.cfm?type=note&q=A37&qt=noteID&criteria=721

8. MBS Requirements  Document consent  Written plan  Person agreed goals  2 ongoing providers  Collaboration with other providers http://www9.health.gov.au/mbs/fullDisplay.cfm?type=note&q=A37&qt=noteID&criteria=721

9. Review & Renew Periods  3-6 months review  12-24 months care plan  Clinical guidelines  Exceptional circumstances MBS Online http://www9.health.gov.au/mbs/fullDisplay.cfm?type=note&q=A37&qt=noteID&criteria=721

10. Person Centred Assessment

11. Team Based Care  Collaborative team meeting  Agree on GPN & GP roles  Patient identification  Appointment scheduling  Template selection  Database research  Organisation of recalls Together we can achieve

12. Auto Fills & Short Cuts – GP  I have discussed the care planning process with my patient who has given their consent to have a GPMP/TCA developed with the GPN  I have updated the past history and medications  Illnesses to be included:  Other Providers to be included:  Review period: 3 months

13. Auto Fills & Short Cuts – GPN  Referred by… for preparation of an initial care plan for…  Discussed the process and billing  Discussed referrals and potential costs  Review period of 3 months due to…  Consent given to proceed  Today’s assessment –

14. Setting the Scene  1 hour appointment  Arrange for no interruptions  Active listening  Body language  Open ended questions  Include person in decisions

15. Review History  Look at the billing  Set reason for visit  Update reminders and recalls  Load template  Autofills  Go through the whole file

16. In the Beginning...  BMI  BP, P & regularity, SpO2, BGL  Informed consent  Medications  Pathology  Family history  Smoking, alcohol

17. Needs Assessment  Rate your health 1-10  Main health concern  Duration of illnesses  Knowledge of illnesses

18. Nutrition  Is your diet healthy  Breakfast, lunch, dinner  Fruit & vegetables  Meats, dairy & bread  Water & salt  Processed foods, takeaways, snacks

19. Activity  How active is your lifestyle  Activities you enjoy  Barriers to activity  Specific exercise  Are you stable on your feet

20. Mental Health & Wellbeing  Daily routine  Do you ever feel sad or alone  Do you have any worries  Sleep patterns  Substance use  Self harm, suicidality

21. Medications  Concurrence  Side effects  Complimentary therapies  Regular Pharmacist  HMR

22. Vaccination  Influenza  Pneumococcal  Hep B  dTpa  MMR  Zoster http://www.health.gov.au/internet/immunise/publishing.nsf/content/Handbook10-home

23. Medical Guidelines

24.  22% CVD  10% CRF  68% with diabetes have CVD or CRF   Mortality rate in Indigenous & socioeconomic disadvantaged groups CVD, Diabetes & CRF AIHW 2014 Cardiovascular disease, diabetes & chronic kidney disease: Australian facts: prevalence & incidence

25. Cardiovascular Risk Assessment  TC, LDL, TC:HDL ratio  Triglycerides  LFTs  BP, P, BGL  Statin, antiplatelet  ED  ECG

26. Renal Protection  eGFR  Microalbuminuria  ACR  BP, BGL  U/E/C, K +  ACE or ARB  NSAID

27. Microvascular Circulation  Vision  Feet  Lungs  Cognition

28. Further Investigation  FBE  CRP  Na +  B12  Vitamin D

29. Goal Setting

30. Personal Goals  Person centred  Maximum of 3  Stages of change  Health coaching  SMART Goals  SMall  Authentic  Re-evaluate  Timeframe

31. Advanced Care Directives  Document persons wishes for care & treatment before they are unable to speak for themselves  Discussion with family & GP discussion  Enduring guardian has the responsibility for health care  Enduring power of attorney has the responsibility for financial and real estate affairs http://www.advancecaredirectives.org.au/

32. Collaboration

33. Referrals & TCA  Dietitian, Exercise Physiologist, Podiatrist  Physiotherapist, Osteopath, Chiropractor  Optometrist, OT, Speech Pathologist  Pharmacist, HMR  Dentition  CNC, ACAT  Specialists  List all team care members on care plan

34. Handover  Cruical for successful CDM  Person relays the messages  Post-it note  Phone call  Intranet message  Email  Face to face

35. CDM Folder  Engages person  Personal role  Personal responsibility  Team communication  Houses a contemporaneous and complete health history My Health Plan

36.  Thank the person for coming  Congratulate them on becoming an active participant in their health care  Invite the them to call if they have any questions Acknowledge Person

37. Nurse Case Managers  Ongoing contact  Coordinating care  Disease surveillance  Independent of GP  GPN can be TCA member Person Centred Medical Home

38.  23, 10997, 10987, 732, 2517, 2546, 2713, 2715  Regular appointments  BP, INR, BGL monitoring  Health coaching, goal attainment, education  Weight & activity monitoring  Vaccination  ECG, Spirometry, Dopplers Forward Planning

39. Business Model ConsultationsItem NumberGP TimeGPN TimeBilling GPMP7211045144.25 TCA72315114.30 Reviews7323045432.30 GP Consults2380296.40 GPN Monitoring109977560.00 ECG1170031.25 Bulk Billing10991238.70 TOTAL year120180$ 1317.20 TOTAL month$109.77 TOTAL hour$263.44

40. Web Resources  Better Health Channel  CVC Program  Flinders University  Health Change Australia  MBS Online  RACGP

41. Thank You