Op#misingGPMPs&TCAsfor

ImprovedHealthOutcomes

TodayWe’llCover

1

2 Themosteffec+vetemplatestoeasilycreatemeaningfulcareplans.

TheAudit-ProofCarePlan:MedicarerequirementsforGP

ManagementPlans(GPMPs)&TeamCareArrangements(TCAs).

4 Howtosetupaneffec+vesystemtorecruitandengagepa+ents

3 Howtosimplifyreferralpaperworkandimprovecommunica+onwithAHPs.

5 HowtouseCarePlanstoreallyimproveyourpa+ents’qualityoflife.

WhyCarePlans?

hHp://www.abs.gov.au/ausstats/abs@.nsf/0/692C03405807CF0BCA25773700169C87?opendocument

Someofthechallenges

•  Morepaperwork

•  Complexprocess

•  Confusingeligibility

andreferralcriteria

•  Timeconsuming

•  Notsurewhat

servicestoreferto

•  Morepaperwork

•  Lowrebate

•  Notenoughsessions

foradequate

treatment

•  Confusingsystem

•  Notsurehow

referralswork

•  Mosteligiblepa+ents

don’tknowthe

schemeexists

GPs AHPs Pa+ents

CarePlans:Pros&Cons

Cons

•  TimeconsumingandI’malreadytoobusy!

•  Toomuchpaperworkandredtape

•  Toomuchtokeeptrackof

•  Auditrisk:Couldgetintroublewith

Medicare

•  Ineligiblepa+entsdemandingplanssothey

canseetheiralliedhealth

•  Can’tfindtherightalliedhealthproviders

•  Alliedhealthprovidersdon’twriteback

Pros

•  BeHermanagementofpa+entcondi+ons

•  Reducehospitaladmissions(be+ermanaged

condi2onshavefeweracutecrises/exacerba2ons)

•  Reducedlengthofhospitalstay(reliablemul+disciplinaryteamarrangementsestablishedinthe

communitythatcanprovidefollowupcare)

•  ThewriHenplanisausefulcentraltoolthe

wholeteamcanuseforeaseofpa+ent

management

•  Revenuegenera*ngforproviders

•  Pa*entscanaccesssubsidisedalliedhealthsessions

Chronic Disease Management Styles in

General Practice

Planned Opportunistic Reactive

Patient identified by

screening database

Nurse/GP

appointment

Care Plan initiated

Care Plan finalised &

items claimed.

AHP Referral

generated

Referral requested by

patient during GP

consult

GP identifies:

Patient eligible &

benefit from Allied

Health referral

Care Plan initiated or

booked

Care Plan finalised &

items claimed.

AHP Referral

generated

Care Plan finalised/

created & items

claimed.

Care Plan initiated/

booked

(if eligible)

AHP Referral

generated

GP Management Plans & Team Care Arrangements

GP Management

Plan GPMP (721)

Patient with Chronic IllnessInclude: Problems, Goals, Patient

Actions, Treatments, Review date

Review in 6 months (min claiming period: 3 months)

GPMP RW (732)

If complex condition requiring a multidisciplinary team (at least 2 other providers in addition to the GP)

Team Care

Arrangement TCA (723)

At least 2 other providers delivering different services.At least 1 Allied Health Professional:Exercise Physiologist, Podiatrist, Optometrist, Dietitian, Diabetes and

Asthma educators, etc.May include up to 1 Specialist.

Review in 6 months (min claiming period: 3 months)

TCA RW (732)

Allows patient access to5 AHP services (in total) in a calendar year

New GPMP (721)2 years (min claiming period: 1 year)

New TCA (723)

5 Nurse support/monitoring services - 10997 (Only GPMP needed)

GPMP+TCA formerly “EPC”

721 + 723

Ques#onsandanswersonCDMitemshHp://www.health.gov.au/internet/main/publishing.nsf/Content/mbsprimarycare-chronicdiseasemanagement-

qanda#3_1

Teammemberscouldinclude:Aboriginalhealthworkers

Audiologists

Chiropractors

Diabetes/asthmaeducators

Die++ans

Exercisephysiologists

Mentalhealthworkers

Occupa+onaltherapists

Osteopaths

Physiotherapists

Podiatrists

Psychologists

Speechpathologists

Orthop+sts,Ortho+stsorProsthe+sts

Socialworkers

Optometrists

Pharmacists(HMR).

Otherproviders

Homeandcommunityserviceproviders

Mealsonwheels

Personalcareworkers

Proba+onofficers

WorkcoverRehabilita+onCaseManager

Fitnessinstructorandpersonaltrainer

iftheyarecontribu2ngtotheplan

Specialists

“Onlyonespecialistorconsultantphysiciancanbecountedtowardstheminimumoftwocontribu2ng

teammemberswho,withthecoordina2ngGP,makeup

thecoreTCAsteam.”

2017

2018

Jan

Jan

Dec

Dec

CarePlan

June

June

AlliedHealthReferrals

721+723

Questions and answers on CDM items

http://www.health.gov.au/internet/main/publishing.nsf/Content/mbsprimarycare-chronicdiseasemanagement-qanda#3_1

Communication between providers:

“Communica2onmustbetwo-way,preferablyoralor,ifnotprac2cable,inwri2ng

(includingbyexchangeoffaxesoremail).”

“Thecommunica2onfromthecollabora2ngprovidersmustincludeadviceon

treatmentandmanagementofthepa*ent.”

“…a'blanketagreement'topar*cipateinTCAswouldnotbesufficient.”

“Afaxformbyitselfwouldnotmeettherequirementforcollabora2onifitdoesnot

includethetreatmentorservicestobeprovidedbytheprovider,matchedtothe

specificneedsofthepa*ent.”

Ques#onsandanswersonCDMitems

hHp://www.health.gov.au/internet/main/publishing.nsf/Content/health-medicare-health_pro-gp-pdf-allied-

cnt.htm

Repor#ngrequirementsofAlliedHealthProfessionals

“AwriHenreportisrequiredakerthefirstandlastservice,ormoreokenifclinically

necessary.

WriHenreportsshouldincludeanyinves#ga#ons,tests,and/orassessmentscarried

outonthepa+ent,anytreatmentprovidedandfuturemanagementofthepa+ent’scondi+onorproblem.”

WhatCarePlanslooklike

SampleGoals,Pa#entAc#ons&TreatmentsforCommonCondi#ons

Pa+entswithType2Diabetes(IndividualAssessment)

Item Descrip#on

81100 DiabetesEducator

81110 ExercisePhysiologist

81120 Die++an

•  Assessmentforgroupservices(atleast45minlong)

•  Groupservices(atleast60minlong)

•  Between2and12persons

•  Pa+entsareeligibleforamaximumofeightgroupservicespercalendaryear

•  Eachservicemustbeatleast60minuteslong

•  Uptotwogroupservicesmaybeprovidedconsecu+velyonthesamedaybythesameprovider

Pa+entswithType2Diabetes(GroupServices)

Aboriginal & Torres Strait Islander Items hHp://www.health.gov.au/internet/main/publishing.nsf/Content/health-oatsih-pubs-mbslist

Diabetes Cycle of Care

Measure/Monitor Frequency

HbA1c Onceeveryyear

Comprehensiveeyeexamina+on Onceeverytwoyears

WeightandheightandcalculateBMI Atleasttwiceeverycycleofcare

Measurebloodpressure Atleasttwiceeverycycleofcare

Examinefeet Atleasttwiceeverycycleofcare

TotalCholesterol,Trig&HDL Atleastonceeveryyear

Testformicroalbuminuria Atleastonceeveryyear

eGFR Atleastonceeverycycleofcare

Provideself-careeduca+on Atleastonceeverycycleofcare

Reviewdiet Atleastonceeverycycleofcare

Reviewlevelsofphysicalac+vity Atleastonceeverycycleofcare

Checksmokingstatus. Atleastonceeverycycleofcare

Reviewofmedica+on Atleastonceeverycycleofcare

Items:2517(LevelB)-2521(LevelC)-2525(LevelD)

Asthma Cycle of Care

•  Items:

2546(LevelB)-2552(LevelC)-2558(LevelD)

•  Requirements:•  Atleasttwoasthmarelatedconsulta+onswithin12

months

•  Pa+entwithmoderatetosevereasthma

•  Documenteddiagnosisandassessmentofthe

•  Pa+ent’slevelofasthmacontrolandseverity

•  Reviewofthepa+ent’suseofasthmamedica+on/devices

•  WriHenasthmaac+onplan

•  Asthmaself-managementeduca+on

•  Reviewdocumentedasthmaac+onplan

MBS Claiming Scenarios

Thomas

o OriginalGPMP&TCAinNov2016

o  Used5PodiatryServicesin2016

o  Reques+nganewreferralinJanuary2017formore

podiatry

Ø Canareferralbemadeformoresessions?

Ø Howmanysessionscanhehavethisyear?

Ø Ishealsoeligibleforanewplan?

Ø Isheeligibleforareview?

MBS Claiming Scenarios

Suzy

o OriginalGPMP&TCAinApril2016

o Used3PhysioServicesin2016

o Reques+nganewreferralinMay2017forExercisePhysiologist

Ø Canareferralbemadeformoresessions?

Ø Howmanysessionscanshehavethisyear?

Ø Issheeligibleforanewplan?

Ø Eligibleforareview?

Pa#ent-CentredCare&

Effec#vePrac#ceSystems

Patient-centred Care

• Whatdoes“pa+ent-centredcare”meantoyou?

• Signsofapa+ent-centredconsult:

________________________________________

________________________________________

________________________________________

________________________________________

________________________________________

CarePlanConsult–StepbyStep

Ensurepa*entis

eligibletoday

Answerques#ons/

clarifywhattheCare

Planisfor.Gain

consent.

Updatehistory:

Allergies,Smoking,

Alcohol,Family&

SocialHistory.

Ensurelistof

condi*onsisupto

dateinpa#entfile

Measurements:

BloodPressure,

Weight,etc.

Findoutwhatother

providersor

specialiststheysee

(addtoaddress

book)

Pa*ent-centredneed

“Whatdoyoufeelis

themainissue

affec#ngyourhealth

atthemoment?”

Pa*ent-centred

impact

“Howisthat

affec#ngyour

everydaylife?”

Pa*ent-centredgoal

“Whatwouldbea

goodoutcome/

resultforthat

issue?”

Addaddi*onal

goals/treatments

basedontheir

condi*ons&guide

thepa#entthrough

these.

AgreeonTCA

providers&make

arrangementsto

gainconsent&input

fromproviders.

GenerateReferrals

Giveacopyofthe

plantothepa*ent.

Informthepa#ent

thatthecareplan

willneedreviewing

in6months

Bookinaprogress

appointmentbefore

nextreview(10997),

whereappropriate.

BillItems&Add

RecallforReview

Francesco:58yrsOld

•  NewlydiagnosedwithType2Diabetes

•  BMI:33

•  Seesa“Chiro”tohelpwithhis“s+fflowerback”

•  Wouldliketogetfitagain,butdoesn’twanttomakehisbackworse.

•  “Theboss”(hiswife)cooksallthemealsinthehouse.

Ø  Anyaddi+onalinforma+onyou’dwantfromFrancesco?

Ø  Whatservices(ifany)wouldyouoffer/discuss?

Ø  Wouldyouinvolveanyotherprovidersinhiscare?Ifso,who?

UsingaClinicalAuditToolPENClinicalAuditTool(CAT)

ThePrac#ceProcess-Systemsto

Recruit&EngagePa#ents

Theprac#ceprocess(stepbystep)

12monthplan

1.   Preparetheprac*ce:

Posterorsigninthewai#ngroomtopromoteCarePlans

Nurse/GP#mesandconsul#ngroomallocatedforCarePlanconsults

AllstaffmembersareawareofthereferralprocesstoNurse/GP

Templatesagreedonandfinalised:

Invita#onlefer

CarePlantemplate

Referralforms(UpdateAddressBookwithlocalAlliedHealthProviders!)

Poster/wai#ngroomsign

Pa#entHandouts

Theprac#ceprocess(stepbystep)

2.Databasesearch:Listofac#vepa#entswithachroniccondi#on(i.e.Diabetes)

3.DetermineMedicareeligibilityofthesepa#ents:

RingMedicareproviderline132150.(checkupto7pa+ents/call)OrUsetheMedicareOnlineportaltocheckeligibility

Askifthepa#entiseligibleforitem721&723today.

IfNOTeligiblethencheckifeligiblefor732&732.

4.Flagpa#entfile&recalleligiblepa#ents:

Tip!le+erfollowedbyphonecallthefollowingweekworksbest.

5.   Bookappointment:

Withnursefor20or30minAND

WithGPimmediatelyaiernursetofinalisetheplan.

Tip!IfunabletomakenurseandGPappointmentsonthesameday,thenlet

pa2entsknowbeforehand(intheinvita2onle+er)thatthecheckwilltake

placeover2consults.

6.Oncepa#entsareseen,addthemtorecalldatabaseforfollowupasrequired.

7. Reviewprogressofthe12-monthplanandrelatedpa#entlistsat3,6and9

months.

8. Startanew12-monthplanaieroneyear.

Theprac#ceprocess(stepbystep)

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