GP Management Plan & Team Care Arrangement

ENHANCED PRIMARY CARE
(Provided by ACEDGP Chronic Disease Management Resource Manual, March 2008)

The Enhanced Primary Care (EPC) program was introduced to provide more preventive care for older Australians and improve coordination of care for people with chronic conditions and complex care needs.

The program provides a framework for a multidisciplinary approach to health.
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EPC items are designed to support the role of general practitioners in the provision of coordinated, multidisciplinary primary health care. They provide an environment for GPs and other care providers to work together to provide holistic long term care for people with chronic diseases.
 
Medicare Chronic Disease Management (CDM) items aim to increase care planning options for GPs and allow for the assistance from practice nurses and others. 
 
The CDM items are simpler than in the past and include a service for ‘GP only’ care planning which is called the GP Management Plan (GPMP). 
 
In addition for patients that require services from a multidisciplinary team, the Team Care Arrangements (TCA) item is available.
 
Patients who have a chronic or terminal condition (without multidisciplinary care needs) can have a GPMPl service. Patients who also have complex care needs can have a GPMP, and a TCA service.
 
GPs can be assisted by Practice Nurses, Aboriginal health workers and other health professionals in providing the CDM items.
 
For a detailed explanation on the various questions on Chronic Disease Management items refer to Department of Health and Ageing website.
 
WHAT ARE THE BENEFITS OF CARE PLANNING?
 
Care planning helps to coordinate the services and treatment that a patient with chronic diseases such as diabetes requires and can be used as a tool to organise the care for the patient; systematic care through care planning can help reduce the need for ad hoc, episodic consultations.

 

WHO CAN BENEFIT FROM A GPMP?
  • Patients with a chronic condition, or range of conditions, that significantly impact on their physical and mental wellbeing
  • Patients who have a terminal condition
  • Patients who require aid or adaptive equipment
  • Patients with two or more hospital admissions in the last six months
  • Patients with ten treatments by other health providers e.g. community nurse, physiotherapy and/or a specialist in the last six months
  • Patients with inappropriate service use
  • Patients who require many home and surgery visits
  • Patients who routinely take seven or more medications (including non prescription)
  • Children and young people who have:
    • Significant chronic conditions
    • Multidisciplinary care needs
    • Poor and uncertain prognosis
    • Threats to life or cogntive, social or physical development
    • Medical and/or surgical interventions
    • Functional and developmental limitations to their role in school, recreational and vocational pursuits
    • Parents and/or siblings experiencing social, economic or personal disadvantage
  • Older patients if they have one or more of the following problems:
    • Cognitive impairment, psychiatric problems
    • Falls, poor mobility
    • Incontinence
    • Social isolation, care stress or depression
    • Multiple medical or surgical conditions
    • Need for high level care to remain at home
    • Recent hospitalisation
    • Increasing frailty
    • Diagnosis of a life threatening condition

THE SIX CDM ITEMS:

  1. Preparation of a GP Management Plan 
  • Provides a rebate for a GP to preparea management plan for a patient with a chronic or terminal condition (including patients who have multiple chronic conditions and multidisciplinary care needs)
  • Recommended frequency is once every two years, supported by regular review services
  • The GP (who may be assisted by their practice nurse or other) assesses the patient, agrees with management goals, identifies actions to be taken by the patient, identifies treatment and ongoing services to be provided, and documents these in the GP Management Plan
  1. Review of a GP Management Plan 
  • Provides a rebate for a GP to review a GP Management Plan 
  • Practice nurse or other can assist
  • Recommended frequency is once every six months; can be earlier if clinically required
  • Involves reviewing the patient’s GP Management Plan, documenting any changes and setting the next review date
  1. Coordination of Team Care Arrangements
  • Provides a rebate for a GP to coordinate the preparation of Team Care Arrangements for a patient with a chronic or terminal medical condition who also requires ongoing care from a multidisciplinary team of at least three health or care providers.
  • In most cases the patient will already have a GP Management Plan in place but this is not mandatory
  • Recommended frequency is once every two years, supported by regular review services
  • Involves a GP (who may be assisted by their practice nurse or other) collaborating with the participating providers on required treatment/services and documenting this in the patient’s TCA
  1. Coordination of a Review of Team Care Arrangements
  • For patients who have a current TCA and require a review of their TCA.
  • Recommended frequency is once every six months; can be earlier if clinically required.
  • Involves the GP (who may be assisted by their practice nurse or other) collaborating with the participating providers on progress against treatment/services and documenting any changes to the patient’s TCA
  1. Contribution to a multidisciplinary care plan being prepared by another health or care provider
  • For patients who are having a multidisciplinary care plan prepared or reviewed by another health or care provider (other than their usual GP)
  • Recommended frequency is once every six months; can be earlier if clinically required
  • Involves the GP (who may be assisted by their practice nurse or other) collaborating with the providers preparing or reviewing the plan and including their contribution with the patient’s records
  1. Contribution to multidisciplinary care plan being prepared by another health/care provider for resident in Aged  Care Facility 

ACCESS TO ALLIED HEALTH SERVICES UNDER MEDICARE

Patients who have both a GP Management Plan and a Team Care Arrangements service have access to the Allied Health Services on the Medicare Benefits Schedule. More information on the items is included in this section under “Allied Health Services”.

Residents of aged care homes whose GP has contributed to a care plan prepared by the aged care home have access to the allied health services.
In summary:
  • Maximum of five services per patient each calendar year 
  • Patient must have an Enhanced Primary Care (EPC) plan prepared by their GP
  • GP refers to allied health professional
  • Allied health professional must report back to the referring GP
ELIGIBLE PATIENTS
 
Patients who have a chronic condition and complex care needs that are being managed by their GP under an Enhanced Primary Care (EPC) plan may be eligible.

A chronic medical condition is one that has been (or is likely to be) present for six months or longer. It includes conditions such as asthma, cancer, cardiovascular disease, diabetes, musculoskeletal conditions and stroke.

Patients have complex care needs if they need ongoing care from a multidisciplinary team consisting of their GP and at least two other health care providers.
 
Referrals must be made using an EPC Program Referral form for individual Allied Health Services under Medicare. This form is available on the Department of Health and Ageing website: www.health.gov.au/epc