1. General Practice Gold Coast Chronic Disease Management from a Whole of Practice Perspective

2. Objectives Increase awareness of Chronic Disease Management Provide information on CDM MBS item numbers Increase awareness of how to implement CDM into General Practice Opportunity to network with peers

3. Approximately 70 per cent of the total burden of disease in Australia is attributable to 6 disease groups, all of which have the potential to be either prevented or managed in settings other than hospital care The Australian Government responded to the growing burden of chronic disease with a number of initiatives to prevent and manage chronic disease within the primary care setting Chronic Disease Management

4. Chronic Disease Framework Chronic Disease Management (CDM) In 2005 the GP Enhanced Primary Care (EPC) care planning items/terminology became obsolete and were removed from the MBS these were replaced by the Chronic Disease Management (CDM) items (721-731). The term 'EPC plan' is now obsolete. There are no changes to the eligibility requirements for the CDM items, including the allied health services for people with chronic disease. This is simply a change to terminology to bring it up to date. The CDM framework is supported by incentives designed to encourage best practice management of CD in primary care

5. Practice Incentives Program (PIP) The aim of the PIP is to provide incentives that encourage general practices to deliver quality care to patients Practices are required to be accredited or working towards accreditation with the RACGP Standards for General Practices Website: www.racgp.org.au/standards

6. Service Incentive Payments (SIP) These payments have been put in place to encourage evidence-based, best practice systems of care for patients with diabetes and asthma and for prevention of disease through immunisation and Pap tests General practices must be participating in the PIP to be eligible to receive SIP payments Claiming of SIP item numbers through Medicare triggers additional ‘payments for quality’ (the application of best practice clinical guidelines)

7. CDM and the MBS The MBS provides incentives for GPs to provide: proactive, coordinated care for their patients through the CDM items There are now 5 CDM MBS items that provide rebates for GPs to manage chronic disease by 1. Preparation of GP management plans (GPMPs) Item 721 2. Coordination of team care arrangements (TCAs) Item 723 3. Review of GPMPs and TCAs. Item 732 4. Contribution to and review of multidisciplinary care plans (MCPs). Items 729 and 731

8. Eligibility CDM service is for a patient who has at least one medical condition that: (a) has been (or is likely to be) present for at least six months; or (b) is terminal.

9. 1. Preparation of a GP Management Plan. Item 721 Comprehensive care planning underpins the effective delivery of CDM. The GPGC provides a vehicle to enhance concordance between the GP and patient, empowering the patient to take responsibility for their goals and encouraging improved self-management The GPMP is a mechanism designed to support the GP and practice staff in care planning and disease management processes

10. Steps required to implement GPMP Explain The steps involved to the patient (and the patient’s carer if appropriate) Develop And document the GPMP Obtain And document the patient’s agreement Offer A copy of the plan to the patient and the patient’s carer, if appropriate Record The plan in the patient’s medical record

11. GPMP A GP Management Plan document should include: 1. The patient’s conditions, problems and health care needs 2. Treatment targets and goals as agreed with the patient 3. Actions to be taken by the patient such as therapy adherence and lifestyle changes 4. Treatment and services the patient needs and arrangements for these 5. A plan to review the GPMP by a date specified

12. 2. Coordination of Team Care Arrangements (TCA) Item 723 Optimal care for patients with complex chronic disease(s) needs often involves a coordinated team of health care providers A TCA is a tool within the MBS designed to support coordinated care with a collaborating team of providers Prior to the TCA, patients should have a GPMP developed Development of the TCA involves identification of appropriate team care providers, referrals and communication with the care providers

13. When coordinationg the development of a TCA the GP must: Consult with at least two collaborating providers Prepare a document (GPMP) that describes 1. Treatment and service goals for the patient 2. Treatment and services that collaborating providers will provide to the patient 3. Actions to be taken by the patient 4. Arrangements to review by a date specified Explain the steps involved to the patient and the patient’s carer, if appropriate Discuss with the collaborating providers who will contribute to the TCA and provide treatment and services under those arrangements

14. Cont.. Record the patient’s agreement to the development of TCA Give copies of the relevant parts of the document to collaborating providers Offer a copy to the patient and the patient’s carer, if appropriate Add a copy of the document to the patient’s medical records

15. The PN may assist with the GPMP/TCA preparation by Providing relevant and comprehensive information for the documents Discussing the GPMP/TCA process with patients, facilitating the development of patient centred treatment goals Educating patients on self management skills Coordinating communications with the care team

16. 3. Review of a GPMP or TCA Item 732 A GPMP or TCA review is designed to support the continuity of care and continued focus on best practice care for patients with CD GPMPs and TCAs can be reviewed by a GP from the same practice or, if the patient changes practices, by their new GP The process for reviewing a GPMP or TCA document with a patient includes: Review patient self-management goals Discuss barriers to the achievement of goals Discuss potential solutions to these barriers Consider additional plans for support such as referral to AHP Reset goals for the next 3 to 6 months

17. When reviewing a GPMP, TCA or multidisciplinary care plan the following steps are required Explain to the patient and the patient’s carer the steps involved in the review Record the patient’s agreement to the review of the plan Review all the matters set out in the relevant plan and for TCAs, collaborating health care providers should provide updates on the treatment/services they provide Make any required amendments to the patient’s plan Offer a copy of the amended document to the patient and the carer and give copies of the amended plan to the collaborating providers Set a date for next review of the plan Add a copy of the amended document to the patient’s records and Provide for further review of the amended plan by a date specified in the plan

18. 4. i) Contribution to or review of a Multidisciplinary Care Plan. Item 729 and 731 Item 729 is available to patients in the community, hospital discharge patients (private and public) and patients not cared for in a residential aged care facility Item 731 is available only to patients who are residents of aged care facilities A multidisciplinary care plan is a written plan that is prepared for a patient by A collaborating provider (other than a medical practitioner) in consultation with two other providers, each of whom provides a different service to the patient Describes treatment and services to be provided to the patient by the collaborating providers

19. When contributing to a multidisciplinary care plan or to a review of the care plan, the medical practitioner must: Prepare Part of the plan or amendments to the plan and add a copy to the patient’s medical records or Give Advice To a person who prepares or reviews the plan and record in the patient’s medical records, any advice provided

20. General Practice Team Roles and Responsibilities Development of a team approach to patient centred care delivered through general practice will ensure maximum efficiency and effective CDM The practice team needs clear communication and direction with regard to roles and responsibilities in implementing a systematic approach to CDM

21. 21 Patient GP/PN GP team Training & Development Diabetes Educator Dietitian Podiatrist Physiotherapist Audiologist Psychologist Aboriginal Health Worker Speech Therapist Exercise Physiologist Mental Health Worker Occupational Therapist Osteopath Chiropodist Chiropractor Pharmacist Optometrist Specialist Consultant ACAT Assessment Respite Community Services Veterans Affairs Meals on Wheels Personalised Education Annual Cycle of Care Collaborative & Transdisciplinary Organisation & Systems Teamwork Leadership Info Mgt & Tech Patient self management Developing relationships Resources

22. Primary Care Practice Team Patient/ Client Carers Resources State, Fedral and Community Specialist Providers Allied Health Providers

23. GP team Roles and Responsibilities General practice must be well organised to implement effective chronic care. This requires teamwork and practice systems to support team care and the use of evidence-based guidelines Effective CDM teamwork in general practice encompasses GPs, clinical and non-clinical staff each with clearly defined roles and opportunities to provide feedback and input into how the system is implemented and CD is managed

24. General Practitioner GPs remain the focal point for the management of patients with CD and are responsible for encouraging a focus on systematic approaches for proactive management of patient care Understand best practice and current guidelines for management of chronic disease Provide leadership within the practice to build a patient centred focus Make clinical decisions with regard to targets, treatments, services and referrals Provide support for PN including training and time for collaboration, time to develop, clean and maintain databases Obtain patient consent to share medical information required for CDM items

25. Practice Manager The practice manager’s role underpins the capacity and capability of practices and staff to effectively manage patients with chronic disease Manage the practice environment including PIP accreditation processes, clinical management software, health records management and occpational health and safety Manage the financial aspects and billing practices, improve efficiency, contracts and optimising the use of professional resources Manage, coach and develop practice staff, build the practice base and the capacity to adapt to change Identify, integrate and mobilise CDM programs and community resources

26. Practice Nurse Practice nurses play an important role in the management of patients with CD and in the overall organisation required to support CDM Provide CDM support through clinical nursing services, patient assessment, planning an coordinating care for patients, preparation of GPMPs, diagnostic services and recommendations for therapy or referrals Run disease specific clinics and preventive health programs including patient self-management education

27. Develop care networks and systematic approaches to patient identification, registers, recalls and reminders, database cleansing Integrate service delivery, network with other services and provide feedback and connectivity between the services, patients and GP Develop and maintain practice and patient educational resources and health promotion

28. CDM Implementation in Practice The Chronic Disease Management Process Effective and efficient management of patients in primary care requires the implementation and maintenance of systematic approaches utilising the practice clinical software as the primary platform

29. Implementation of a systematic approach to CDM should include the following steps: Practice Audit Identify care patterns in the practice and information gaps Patient Disease Register Develop a disease register which requires GPs and staff to utilise the functionality of the software Patient Identification Search the electronic system to identify patients who meet recall eligibility criteria

30. Cont... Recall and Reminder Systems Develop a system for recalling patients and appointment reminders Patient Review and Assessment Review patient medical history, diagnoses, medications and undertake a patient assessment Documentation and Care Planning Coordinate GPMPs. TCAs, multidisciplinaty care plans, plan for reviews, and communicate with the provider team

31. 1 st Visit – CDM 2 nd Visit – CDM 3 rd Visit – CDM 4 Visit 5 th Visit - CDM 6 th Visit 1 st Visit – CDM 2 nd Visit – CDM 3 rd Visit – CDM 4 Visit 5 th Visit - CDM 6 th Visit Preparation of a GPMP – Item 721 Consider Group Allied Health Referrals Preparation of a GPMP – Item 721 Consider Group Allied Health Referrals Coordination of TCA – Item 723 Consider Individual Allied Health Referrals Coordination of TCA – Item 723 Consider Individual Allied Health Referrals Review GPMP and TCA Coordination – Item 732 Utilise Item 732 Twice in this Visit* Review GPMP and TCA Coordination – Item 732 Utilise Item 732 Twice in this Visit* Level A, B, C or D Consult Mid-Year Diabetes Review Level A, B, C or D Consult Mid-Year Diabetes Review Review GPMP and TCA Coordination – Item 732 Utilise Item 732 Twice in this Visit* Review GPMP and TCA Coordination – Item 732 Utilise Item 732 Twice in this Visit* Level B, C or D Consult Complete Annual Diabetes Cycle of Care - Item 2517, 2521 or 2525 Level B, C or D Consult Complete Annual Diabetes Cycle of Care - Item 2517, 2521 or 2525 Group Services: Credentialed Diabetes Educator Exercise Physiologist Dietician Individual Services: Credentialed Diabetes Educator Dietician Podiatrist Dentist Review Reports from Credentialed Diabetes Educator Dietician Podiatrist Dentist Group Services: Credentialed Diabetes Educator Exercise Physiologist Dietician Individual Services: Credentialed Diabetes Educator Dietician Podiatrist Dentist Review Reports from Credentialed Diabetes Educator Dietician Podiatrist Dentist Diabetes Incentives & CDM: Includes a full explanation of the Diabetes Cycle of Care Diabetes Incentives & CDM: Includes a full explanation of the Diabetes Cycle of Care Item 10997 Diabetes Care within the MBS Framework Type 2 Diabetes Management and Best Practice within the MBS CDM Framework

32. Chronic Disease Management So now you know what to do, what to bill, and whether CDM is important to your workplace But lets talk about actually introducing CDM into your workplace

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34. Finding time, setting up documentation, making connections with your CDM team and discussing ways of introduction with your team

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36. Every workplace will have a different system, different paperwork and different team profiles. We all have the same common goal to achieve optimum health benefits for our patients

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38. Make time to connect with local allied health. Have templates available Have all team members understanding the purpose of plan and understand booking system

39. Chronic Disease Management Allocate time for plans Assess patients eligibility Have systems in place to check all components are completed

40. Care Plan Hints Care Plans, also known as GP Management Plans previously known as Enhanced Primary Care Provided for patients with chronic disease to assist self management All Patients, check: Contact details including address & phone A&TSI status Past Medical History, including all relevant History is ticked in summary box Family History Social History Smoking Alcohol status Weight Blood Pressure Relevant Pathology – Hba1c, microalbumin, lipids, egfr – when were they last done? Chronic Disease Management

41. Asses what patient’s are eligible for: New plan, 721,723 (can be billed second yearly so check pracsoft billing/contact Medicare Or review, 732 (related to a 721) and a 732 related to a 723 (eligible 12 weeks after last care plan billing but routinely done at 6 months) Therefore if looking at billing cycle could have one billing 721 & 723 followed by 732 in a two year process if timing correct.

42. Chronic Disease Management Patients needing a Team Care Arrangement will require two providers of care other than those provided by a GP. If using new provider in addition to sending Team Care Agreement letter. Call provider to check their acceptance in plan and advise them they will need to send our agreement back. Providers of care must relate to condition seeking need for and provided different services for patient

43. Chronic Disease Management Examples of providers of care include but are not limited to: Allied Health Professionals – Physio, Podiatry, Exercise Physiologist, Psychologist, Dietician, Social Worker, Diabetes Educator. Private Specialists Hearing Clinics School Teacher All completed plans will remain in the surgery until letters of acceptance/previous treatment letters are returned and Medicare billed.

44. Chronic Disease Management The Nurse in collaboration with your Doctor will establish your eligibility to have a care plan and this will be on your medical history. A care plan may allow access to some funding from Medicare for Allied Health services.

45. Chronic Disease Management Assessment Booking Sheet – with appointments including: What patient is booking in for Date Column for checked eligibility Drs name

46. Chronic Disease Management Care plan for ________________________________________ Care plan produced on ________________________________ Awaiting Treatment Letter from___________________________ Awaiting Acceptance from_______________________________ When received to bill ___________________________________ DR__________________________________________________ Pt Contacted for collection ________________________________ Date collected/posted____________________________________

47. Chronic Disease Management All clinics will have unique method, individualised plans and systems in place