Chronic Disease Management

Chronic Disease Management
Program contact person: Carolyn Wilson


Overview:
Chronic Disease Management (CDM) in General Practice involves appropriate prevention, early identification and best practice management strategies. The aim of the Chronic Disease Management program is to support GPs and general practice staff in all areas of chronic disease management, focussing on a co-ordinated team based approach. GP Links has compiled a series of templates to assist GPs and their practices with the chronic disease management MBS items – GP Management Plan (GPMP) and Team Care Arrangements (TCA).

The templates are designed to assist GPs in documenting the GPMP and TCA. Summary checklists produced by the Department of Health and Ageing provide an overview of the process to be followed when using the MBS item numbers. It is recommended that the explanatory notes relating to these item numbers in the Medicare Benefits Schedule be read and understood to ensure that all requirements are complied with.

The templates compiled by the Division include both generic templates that can be used for any chronic disease and disease-specific templates. The disease-specific templates incorporate evidence-based guidelines for the management of those diseases, these guidelines can be used as a prompt of issues to be addressed with each patient. The templates are designed to be all inclusive on the basis that is easier to delete information that it is not relevant to a particular patient.

It is anticipated that doctors using these templates will review and adapt them to meet their own practice population needs, and save the revised version as their own basic template.

The disease-specific templates are a starting point for discussions between a GP and patient. The templates are intended to be individualised in accordance with the particular needs and problems of each patient.

It is acknowledged that many patients will have co-morbidities beyond those covered in the disease-specific templates. Where patients have co-morbidities, all health issues can be addressed in the one GPMP and/or TCA. The disease-specific templates can be used as a starting point with other chronic conditions added as necessary to address the needs of the patient.

Chronic Disease Management (CDM), Enhanced Primary Care (EPC), Medical Benefits Scheme (MBS) items at a glance:

What is Chronic Disease?
Over three million Australians, or nearly one in seven, suffer from chronic disease and the problem is likely to be one of the great health challenges for Australia and the workforce in the 21st Century.

Chronic disease and conditions are generally defined as those which are long term (lasting more than 6 months), non-communicable, involving some functional impairment or disability usually incurable. They can affect people of all ages and contribute to the disease burden in our society.

Chronic Diseases such as: diabetes, Cancer, Cardiovascular Disease, Asthma and certain Mental Health conditions are among the most significant contributors to morbidity and mortality in Australia and as such have been recognised as National Health Priority Areas.

How can General Practice help in Chronic Disease Management (CDM)?
CDM in General Practice involves appropriate prevention, early identification and best practice management strategies.

As the GP is usually the first point of contact in the health system GPs and PNs have a key role to play in the primary intervention, prevention, diagnosis and management of chronic disease in the community. 

What is Enhanced Primary Care?
The Enhanced Primary Care Program (EPC) program was introduced to provide more preventive care for older Australians and improve coordination of care for people with chronic conditions and complex care needs. The program provides an opportunity for the GP to prepare, review, or contribute to, a comprehensive and expansive plan for the care of an individual patient with a chronic condition and complex care needs requiring multidisciplinary care.

Chronic Disease Management MBS Items
For the first time GPs have access to Medicare rebates for preparing and reviewing GP Management Plans for patients with chronic medical conditions. For patients requiring multidisciplinary care, GPs can also claim from Medicare for coordinating team care planning and review services.

Who does it apply to?
The CDM items apply to treatment of people with asthma, cancer, arthritis, diabetes, heart disease, mental illness and other chronic medical conditions.

Templates:
• MBS item 721
• MBS item 723
• Patient Consent Form
• EPC program referral form for Allied Health Services under Medicare
• EPC RN request & consent form

Resources:
• Frequently used MBS items
• CDM checklist
• GPMP checklist
• GPMP flowchart
• TCA checklist
• TCA flowchart
• EPC & CDM item numbers: Finding your way through the maze

 Links:
• DoHA: Enhanced Primary Care Program (EPC): Chronic Disease Management (CDM) Medicare Items
• DoHA: Enhanced Primary Care Program (EPC): Dental Services under Medicare
• Medicare Items for Managing Chronic Disease 2008