CDM Overview

DEFINING CHRONIC DISEASE

“Chronic diseases and conditions can affect people of all ages and are generally defined as those which are: 

  • long term (lasting more than 6 months)
  • non-communicable 
  • involving some functional impairment or disability
  •  usually incurable.”
“A patient must have a chronic (or terminal) medical condition - one that has been or is likely to be present for 6 months or longer, including but not limited to asthma, cancer, cardiovascular illness, diabetes mellitus, musculoskeletal conditions and stroke. Patients who also have complex care needs are eligible for Team Care Arrangements. Patients with mental disorders are eligible for GP Mental Health Care items.” (Chronic Disease Management Resource Manual - ACEDGP March 2008)
 
Australia is facing an increasing economic and social burden due to chronic diseases. By 2016, an estimated 16% (3.5 million) of the Australian population will be experiencing the effects of chronic disease. (AIHW Catalogue No PHE–33. Canberra: AIHW, 2002)
 
A NEW APPROACH

A population health approach is recognised as the most effective way to address the morbidity and mortality impacts of chronic disaease. 
This approach is based on a disease continuum from prevention, early identification, best practice management, rehabilitation and palliative care.
Establishing a system within the practice is important and check lists and templates are available to streamline the process. Unlike the previous EPC Medicare item numbers, the role of the practice nurse or Aboriginal health worker in the preparation of both a GPMP and a TCA is now clearer and more inclusive, depending on internal practice arrangements and individual competencies. While the GP must see the patient and confirm all assessments and arrangements, the practice nurse could assess the patient, assist with preparing a GPMP, identify the patient’s needs, facilitate communication between the GP and other health providers, discuss costs with the patient, and provide patient education and self management information.
Following consultation with GP representative groups, changes to the EPC item numbers were recommended and came into effect on 1 July 2005. The new CDM item numbers offer GPs alternatives in the management of chronic and complex conditions and are now available to a wider group of patients. The CDM item numbers represent an opportunity to improve chronic disease management through general practice and offer eligible patients access to allied health services. They also provide a system to remunerate GPs for the time and effort required to plan and coordinate care of patients with a chronic illness. (J. Newland Australian Family Physician Vol. 35, No. 1/2, January/February 2006).