An Introduction toCare Planningin General PracticeJacki Kerr, Prevention PartnersBSPHN15 March 2018

Agenda The Medicare CDM Strategy Identifying patients for chronic disease registers The CDM Item Numbers for GPs Minimum requirements for plan inclusions Example templates Reviews Allied Health Professional referrals Group Allied Health sessions GP Mental Health Treatment Plans

The Medicare CDM Strategy – history Exists to provide structure, guidance and remuneration toGPs for managing complex chronic disease patients Formerly known as “Enhanced Primary Care” or “EPC” Other names have included “Care Plans” Different structures since its inception in 1999 Current: Chronic Disease Management

The Medicare CDM Strategy - current A chronic medical condition six months or longer There is no list of eligible conditions; however .patients who require a structured approach & amultidisciplinary team Eligibility for CDM services is a clinical judgement forthe management

The Medicare CDM Strategy – 3 essential Search For Health Professionals Medicare Primary CareSearch by Item number forrules and notesThis one is paramount to yourrole assisting the GP

Preparation saves timeBefore you see a CDM patient, collectas much data about them as possiblefrom their chart Use of an Assessment cheat sheet ishighly recommended

FYI A practice nurse, Aboriginal and Torres Strait Islander healthpractitioner, Aboriginal health worker or other healthprofessional may assist a GP with items 721, 723, and 732 (e.g. inpatient assessment, identification of patient needs and makingarrangements for services). However, the GP must meet allregulatory requirements, review and confirm all assessments andsee the patient. Ref: Notes Section A36

CDM Item Numbers – there are 6 for GPs 721: Preparation of a GP Management Plan (GPMP) 732: Review of a GPMP 723: Coordination of a Team Care Arrangement (TCA) 732: Review of a TCA 729: Contribution to a Multidisciplinary Care Plan being preparedby another health or care provider (hospital discharge) 731: Contribution to a Multidisciplinary Care Plan for a residentof an aged care facility

Timeline of a CDM Program – by Medicare billing guidelines3 months721 723GPMP TCAOnce per year732 x 2Reviews3 months732 x 2Reviews3 months732 x 2Reviews721 723GPMP TCAOnce per year12 months 1 dayExample:1 February 20181 May 20181 Aug 20181 Nov 20182 February 2019

Timeline of a CDM Program – more often4 - 5 months721 723GPMP TCAOnce per year4 - 5 months732 x 2Reviews732 x 2Reviews721 723GPMP TCAOnce per year12 months 1 dayExample:1 February 2018May 2018October 20182 February 2019

Timeline of a CDM Program – most patients?6 months721 723GPMP TCAOnce per year732 x 2Reviews721 723GPMP TCAOnce per year12 months 1 dayExample:1 February 2018August 20182 February 2019

721Preparation of a GP Management Plan (GPMP) Chronic/terminal disease management, with or withoutmultidisciplinary care needs The minimum claiming period is once every twelve months

721 GPMP: minimum inclusions A comprehensive written plan must be prepareddescribing: (a)the patient's health care needs, health problems and relevantconditions; (b)management goals with which the patient agrees; (c)actions to be taken by the patient; (d)treatment and services the patient is likely to need; (e)arrangements for providing this treatment and these services; and (f)arrangements to review the plan by a date specified in the plan.

723Coordination of a Team Care Arrangement (TCA) for a patient who has a chronic or terminal medical condition andalso requires ongoing care from a multidisciplinary team of at leastthree health or care providers. In most cases the patient will already have a GPMP in place. The minimum claiming period is once every twelve months.

723Coordination of a Team Care Arrangement (TCA) When coordinating the development of Team Care Arrangements (TCAs), the medicalpractitioner must: (a) consult with at least two collaborating providers, each of whom will provide adifferent kind of treatment or service to the patient, and one of whom may be anothermedical practitioner, when making arrangements for the multidisciplinary care of thepatient; and (b) prepare a document that describes: i.treatment and service goals for the patient; ii.andtreatment and services that collaborating providers will provide to the patient; iii.actions to be taken by the patient; iv.arrangements to review (i), (ii) and (iii) by a date specified in the document.

Can a Nurse or AHW be one of the 3members of the TCA team?Ref: Section 3.12 of the CDM Q&A document (2014)“Under what circumstances can a nurse/practice nurse, Aboriginal and Torres Strait Islanderhealth practitioner or Aboriginal health worker be one of the three minimum members of amultidisciplinary Team Care Arrangements (TCAs) team? “ If a nurse/practice nurse/Aboriginal and Torres Strait Islander health practitioner or Aboriginalhealth worker is independently providing ongoing treatment or services to the patient, that is: not as part of the general practice medical services provided by the GP; not under the supervision of the GP; and different to the ongoing care provided by the other members of the team; they could constituteone of the minimum three members of the team.Where the nurse/practice nurse is: providing general practice services on behalf of the patient’s GP (including Medicare items forimmunisation, wound management and Pap smears, which must be provided on behalf of and underthe supervision of a GP); and/or otherwise providing services under supervision, not in their own independent professional capacity;they could not qualify as one of the three independent members of the team.

Cont’d Within the general guidance above, it is up to the GP todetermine in the specific circumstances whether thepractice nurse is skilled or qualified to independentlyprovide ongoing treatment or services to the patient that isdifferent to the care provided by the other members of theteam. If a GP believes that there is a clear case for the practicenurse to qualify as one of the minimum three members of aTCAs team, given the particular needs and circumstancesof the patient and the treatment to be provided by thepractice nurse, the GP should be clearly satisfied that theirpeers would regard the involvement of the practice nurseas a member of the TCAs team to be appropriate in thecircumstances.

Example of a TCA – please note1.Try to include as much details as possible: name, address,phone & fax2.Only 1 Specialist or Consultant Physician can be countedtowards the team of 3 making up the core TCA team3.A patient can see a different AHP at the same location (ega group Physio practice) but they cannot go to a differentPhysio practice altogether. A new AHP referral form wouldbe required to change AHP practice

732Review of a GPMP Provides a rebate for a GP to review a GPMP The minimum claiming period is once every threemonths Involves reviewing the patient’s GP ManagementPlan, documenting any changes and setting thenext review date.

732Review of a TCA Provides a rebate for a GP to review a TCA The minimum claiming period is once every three months Involves the GP (who may be assisted by their practicenurse or other) collaborating with the participatingproviders on progress against treatment/services anddocumenting any changes to the patient’s TCAs.

Medicare requirements when item 732 isclaimed twice on the same day If a GPMP and TCA are both reviewed on the samedate and item 732 is to be claimed twice on thesame day, both electronic claims and manualclaims need to indicate they were rendered atdifferent times Ref: Notes Section A36

Patient ConsentNumber of pathways for patient to consent: Implied They Yourconsent (they visit the Practice regularly)respond to letter or phone callrole as Nurse/AHW: ensure patient understandspurpose and agrees to assessment prior to commencing

Summary of CDM Item numbersItem NumberNotes721 Can be just the GP AHW/Nurse involvedin patient care Set treatment goals and actions Set a review date AHW/Nurse can assist the GP to preparethe documentation723Minimum 12 monthsTeam CareArrangement Patient has complex care requirements Patient requires a team of health careproviders to manage condition Minimum of 3 health professionals732 GP AHW/Nurse review patient progress Document changes & set next dateOnce every ncyMinimum 12 months

The Medicare Subsidised Allied HealthReferral Scheme Patient must have a GPMP and a TCA in place GP only to refer to AHP AHP must write back to GP Subsidy for up to 5 sessions per calendar year (total) Who is included in the scheme?.

Eligible Allied Health ProvidersAHPItem NumberAboriginal Health Workers or Aboriginal andTorres Strait Islander Health 964Diabetes Educators10951Dietitians10954Exercise Physiologists10953Mental Health Workers10956Occupational 0Podiatrists10962Psychologists10968Speech Pathologists10970

Referral Form for AHP Services Finding the form Import it as a template Discuss how you utilise it as a table hing.nsf/Content/Chronic Disease Allied Health Individual Services

How to Communicate with AHPs for theSubsidy Scheme1.Seek their agreement to be a part of the patient’s management (phoneideal); document agreement somewhere2.Include the AHP within the TCA (contact details, treatment/services)3.Complete an AHP referral form for every provider (but only total of 5 visits)4.Fax this referral form to the AHP once the Item numbers (721 723) havebeen billed by GP5.Send a copy of the GPMP TCA to the AHP (fax OR via the patient)6.Include details of progress within the Review document at next visit (3-6/12later)

Reporting requirements - allied healthproviders to GP A written report is required after the first and lastservice, or more often if clinically necessary.

Group Allied Health Servicesfor Patients with Type 2 ian

DiabetesEducatorExercisePhysiologistDietitian The patient must have a GPMP in place, but does not require a TCA There are two elements to provision of allied health services underthese items:1 initial assessment8 group sessions Group services are in addition to the 5 individual allied healthservices available GP is required to refer using the specific Group AHP Services referralform

Group Allied Health Services for patients with Type 2 1058111581125(min. 45 mins)Group Services(at least 60 mins)2 – 12 patientsIf a provider accepts the Medicare benefit as full payment for the service, therewill be no out-of-pocket cost. If not, the patient will have to pay the differencebetween the fee charged and the Medicare rebate.

Group Allied Health Services for patients with Type 2 DiabetesAHPup to 5 visitscan besubsidisedper calendaryearAHP1 initialassessment(individual) &up to 8 groupsessions percalendar year1 assessment per calendar year.8 group sessions (may be mixed)Up to 14Medicarerebateable AHPvisits percalendar year

GP Mental Health Treatment Plans Provided under the “Better Access to Mental Health” framework These services are provided only by GPs Psychiatrists clinical psychologists registered psychologists, and appropriately trained social workers and occupational therapistsNurses in General Practice cannot assist with these plans, unlike and-allied-health

GPs can provide the following servicesunder Better Access:ServicePrepare a GP mentalhealth treatment plan(GPMHTP)Review a mental healthtreatment planMBS itemFrequency it can be used2700, 2701, 2715 or 2717Once every 12 monthshowever not within 3months of a review underitem 27122712Once every 3 monthshowever not within 4weeks of claiming item2700, 2701, 2715 or 2717Manage a patient’s mental 2713 or a generalhealth conditionconsultation itemAs often as necessary - norestrictions*GP focused psychologicalstrategies (FPS) servicesUp to 10 services every 12months2721 - s-and-allied-health

Mental Health Treatment Plans All consultations conducted as part of the GP Mental Health Treatment itemsmust be rendered by the GP and include a personal attendance with thepatient. A specialist mental health nurse, other allied health practitioner, Aboriginal andTorres Strait Islander health practitioner or Aboriginal Health Worker withappropriate mental health qualifications and training may provide generalassistance to GPs in provision of mental health care. item&q 2715&qt ItemID

Mental Health TP and CDM Together? It is preferable that wherever possible patients have only one plan for primarycare management of their mental disorder. As a general principle the creation ofmultiple plans should be avoided, unless the patient clearly requires an additionalplan for the management of a separate medical condition. The Chronic Disease Management (CDM) care plan items (items 721, 723, 729, 731and 732) continue to be available for patients with chronic medical conditions,including patients with complex needs. Where a patient has a mental health condition only, it is anticipated