Chronic Disease Management (CDM)

WentWest provides support to general practice through resources, education and practice visits on Chronic Disease Management (CDM). Chronic Disease Management (CDM) in General Practice involves appropriate prevention, early identification and best practice management strategies.

GPs and practice nurses have a key role to play in the primary intervention, prevention, diagnosis and management of chronic disease in the community, as General Practice is usually the first point of contact in the health system.

WentWest CDM assistance

• Support of General Practice in CDM through practice visits, education and training with General Practitioners, Practice Nurses, General Practice staff, Associate/Affiliate Members and other providers in the community; Promotion, development and maintenance of relationships with general practice, other service providers and consumers at the local level to improve patient access to quality, timely and co-ordinated care;
• Keeping abreast of relevant state and national initiatives to enable the identification of future directions in primary care and potential opportunities for collaborative programs and resource sharing at national, state and local levels.

Support

• Primary Care Home
• Medicine Review (HMR)
• Medical Director assistance and templates
• National Prescribing Service (NPS)
• PIPs & SIPs (for accredited practices)
• Recall and Reminder Systems Templates
• Utilising a Practice Nurse in CDM

Topics covered:

• GP Management Plans
• Team Care Arrangements
• Reviews
• Billing and Claiming GPMP, TCAs and Reviews
• Asthma
• Diabetes
• Coronary Heart Disease 

 

GP Management Plan

Patient Eligibility

A GP Management Plan may be completed by the patients usual GP for any patient with a chronic condition.  A chronic condition is one that is likely to last six months or longer or is terminal.  

Contents

The GP Management Plan includes:

•  A written action plan, including management goals with a planned review date;
• A comprehensive assessment of patient needs;
• Agreement upon management goals for the patients’ condition;
• Actions to be taken by patient; and
• Identified treatments or services for the patients needs.

 

Team Care Arrangements

Patient Eligibility

A Team Care Arrangement may be completed or contributed to the patients usual GP for any patient with a chronic and complex condition.  A chronic condition is one that is likely to last six months or longer or is terminal, while a complex condition is one that requires a multidisciplinary team.  

Contents

A Team Care Arrangement includes:

• The GP and a least two other formal care providers, who provide separate and ongoing care;
• Active consent and contribution from all providers to the TCA;
• A comprehensive assessment of patient needs;
• Documented goals, management by each provider, patient actions, review date; and
• Informed patient consent for information sharing and possible costs.

 

Reviews

Patient Eligibility

GP Management Plans and Team Care Arrangements should be reviewed every 3 months.   

Contents

Reviews should include:

• A review of needs, goals, actions, treatments and servicesDocumentation of changesSetting a new review date; and
• Collaboration with other providers (TCA only).

Billing and Claiming GPMP, TCAs and Reviews

Name	Item No	Medicare Fee (100%)	Recommended frequency	Minimum Claiming Period
Preparation of a GP Management Plan	721	$136.05	2 yearly	12 months
Coordination of Team Care Arrangements	723	$107.80	2 yearly	12 months
Review of a GP Management Plan or Coordination of Review of Team Care Arrangements/ Multidisciplinary Community Care Plan/ Multidisciplinary Discharge Plan	732	$ 68.00	It is the responsibility of the GP to determine whether this is clinically appropriate (Please refer to the fact sheet on correct Medicare billing of CDM manual pg no. 40)	3 months
Contribution to a multidisciplinary care plan or Team Care Arrangements	729	$66.35	6 monthly	3 months
Contribution to a multidisciplinary care plan by an Aged Care Facility	731	$66.35	6 monthly	3 months

 

Asthma

Asthma may be treated in General Practice using either the Asthma Cycle of Care or the GPMA and TCA.  Both schemes should not be claimed in the same twelve months for the same patient due to overlap in the services provided.  It is important to incorporate appropriate Recalls and Reminders into this structured patient care. 

 

Diabetes

Diabetes may be treated in general practice using both the Diabetes Annual Cycle of Care and GMPA and TCA at the same time, these services are complementary and can be claimed for the same patient at the same time.

It is important to incorporate appropriate Recalls and Reminders into this structured patient care. 

 

Coronary Heart Disease

CHD may be treated in general practice using the GMPA and TCA.

It is important to incorporate appropriate Recalls and Reminders into this structured patient care. 

 

Links and Resources

• Medicare Changes to Primary Care Items Fact Sheet

• Chronic Disease Management Resource Manual

Asthma

• Asthma Cycle of Care form.
• National Asthma Council www.nationalasthma.org.au

Diabetes

• Flow Chart for Diabetes Patients
• Established Diabetes Mellitus Cycle of Care Record
• Diabetes Australia NSW www.diabetesnsw.com.au

Coronary Heart Disease

• Flow Chart to Manage CHD Patients
• Indigenous PIPs Fact Sheet
• The Heart Foundation www.heartfoundation.org.au

Home Medicines Review

• HMR Factsheet Oct 2011
• HMR Flowchart Oct 2011

More Information

To find out more about CDM, contact your WentWest Area Services Co-ordinator on (02) 8833 8000 or email: support@wentwest.com.au

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