Chronic Disease Management (CDM) Plans (GP Management Plan, GPMP)

Last updated 13.02.13

 

Index

 

Definition

-  Written plan to co-ordinate health care of a patient with a chronic or terminal medical condition

-  GP & at least 2 other health providers (allied health +/- medical specialist)

-  Chronic medical condition likely to persist for at least 6/12

-  Not hospital in-pts or aged care facility

-  GPMP = GP Management Plan

-  TCA = Team Care Arrangement

 

Features

-  Allows access to Medicare rebates for allied health care

-  Practitioners need to be registered with Medicare

-  Should be completed by pts usual GP

-  Responsible for pts health care for previous 12/12

-  Likely responsible for next 12/12

-  Requires at least 3 members of treating team

-  Allied health

-  Aboriginal Health Worker

-  Audiologist

-  Chiropractor

-  Diabetes Educator

-  Dietician

-  Exercise Physiologist

-  Mental Health Worker

-  Occupational Therapist

-  Osteopath

-  Physiotherapist

-  Podiatrist

-  Psychologist

-  Speech Pathologist

-  Consultant (can only have 1 as member of team)

-  Previously referred to as GP Enhanced Primary Care Plan

-  Examples conditions

-  Asthma

-  Cancer

-  Cardiovascular disease

-  DM

-  MSK: OA, etc.

-  Stroke

-  Mental health issues should be addressed by GP Mental Health Treatment Plans

-  MBS Items

-  CDM Plan = 721

-  Recommended 2nd yearly (1yr minimum)

-  CDM Plan R/V = 732

-  Recommended 6/12 (3/12 minimum)

-  Team Care Arrangement (TCA) = 723

-  Recommended 2nd yearly (1yr minimum)

 

Procedure

-  Comprehensive written plan

-  Pts health care needs & issues

-  Management goals

-  Actions to be taken

-  Treatment & services required

-  Arrangements for these services

-  Plan for R/V

-  Must also document pts agreement/consent

-  Can be done as GP led care without allied health (721)

-  Needs a TCA (723) for allied  health involvement

-  Written referral to each allied health practitioner

-  Allied health/consultant should provide written report back to GP

-  Patient should be offered a signed copy of the plan

-  Recommended for R/V each 6/12

 

 

 

 

References

 

DoH: www.health.gov.au/internet/main/publishing.nsf/Content/mbsprimarycare-chronicdiseasemanagement