Medicare Items for managing chronic disease 2008

1. Medicare Items for managing chronic disease(2008)

2. Introduction These presentation slides are abbreviated � GPs and others should refer to the MBS explanatory notes for details. The CDM items replace the former Enhanced Primary Care (EPC) multidisciplinary care planning items. The CDM items were developed in consultation with GP organisations, and commenced in July 2005. They are intended to be provided by the patient�s usual GP. The CDM items include a service for �GP only� care planning (the GP Management Plan) in addition to services for multidisciplinary care planning (Team Care Arrangements). The CDM items aim to make it easier for GPs to manage the health care of patients with chronic or terminal medical conditions. The CDM items are intended to be provided by the patient�s usual GP. This means the GP, or a GP working in the medical practice, that has provided the majority of care to the patient in the previous 12 months and/or will be providing the majority of care to the patient over the next 12 months. Any services designed to prevent or manage chronic illness are best provided by the GP or practice that will be responsible for the patient�s long term care. The CDM items significantly increase care planning options for GPs, as well as expanding patient eligibility and increasing the assistance that practice nurses and others can provide. A practice nurse, Aboriginal health worker or other health professional can assist a GP in preparing or reviewing a GPMP or TCA, for example, in assessing the patient, identifying the patient�s needs and making arrangements for services. This assistance is provided on behalf of the GP as part of the CDM service. It cannot constitute a separate Medicare service or contribute to a separate Medicare service. The GP must review and confirm all assessments and elements of the service and must see the patient as part of the service. The CDM items aim to make it easier for GPs to manage the health care of patients with chronic or terminal medical conditions. The CDM items are intended to be provided by the patient�s usual GP. This means the GP, or a GP working in the medical practice, that has provided the majority of care to the patient in the previous 12 months and/or will be providing the majority of care to the patient over the next 12 months. Any services designed to prevent or manage chronic illness are best provided by the GP or practice that will be responsible for the patient�s long term care. The CDM items significantly increase care planning options for GPs, as well as expanding patient eligibility and increasing the assistance that practice nurses and others can provide. A practice nurse, Aboriginal health worker or other health professional can assist a GP in preparing or reviewing a GPMP or TCA, for example, in assessing the patient, identifying the patient�s needs and making arrangements for services. This assistance is provided on behalf of the GP as part of the CDM service. It cannot constitute a separate Medicare service or contribute to a separate Medicare service. The GP must review and confirm all assessments and elements of the service and must see the patient as part of the service.

3. The item numbers and fees *CDM services can be provided more frequently in �exceptional circumstances�. This table shows the item numbers, current MBS rebates (at 100% of the MBS fee), recommended frequency and minimum claiming period. The recommended frequency for these services, allowing for variation in patients� needs, is once every two years, with regular reviews (recommended six monthly) of the patient�s progress against their plan. This is not mandatory � in general, a new GPMP or TCA should not be prepared unless and until required by the patient�s condition, needs and circumstances The review items are the key components for assessing and managing the patient�s progress once a GPMP or TCA have been prepared. Minimum claiming intervals are specified to allow for earlier completion of a new GPMP, TCA or review where required. For example, a rebate for a GPMP will not be paid within twelve months of a previous claim for a GPMP etc, other than in exceptional circumstances. *Exceptional circumstances - CDM services can also be provided more frequently in �exceptional circumstances� - where there has been a significant change in the patient�s clinical condition or care circumstances (such as development of co-morbidities or complications, deteriorating condition, illness/death of carer etc), that require a new GP Management Plan, Team Care Arrangements or review service. Where a service is provided in exceptional circumstances, the patient�s invoice or Medicare voucher (assignment of benefit form) should be annotated to briefly indicate the reason (e.g. clinically indicated, discharge, exceptional circumstances, significant change etc). If claims for payment in such circumstances are initially rejected they should be resubmitted for payment, ensuring that the reason is clearly identified. This table shows the item numbers, current MBS rebates (at 100% of the MBS fee), recommended frequency and minimum claiming period. The recommended frequency for these services, allowing for variation in patients� needs, is once every two years, with regular reviews (recommended six monthly) of the patient�s progress against their plan. This is not mandatory � in general, a new GPMP or TCA should not be prepared unless and until required by the patient�s condition, needs and circumstances The review items are the key components for assessing and managing the patient�s progress once a GPMP or TCA have been prepared. Minimum claiming intervals are specified to allow for earlier completion of a new GPMP, TCA or review where required. For example, a rebate for a GPMP will not be paid within twelve months of a previous claim for a GPMP etc, other than in exceptional circumstances. *Exceptional circumstances - CDM services can also be provided more frequently in �exceptional circumstances� - where there has been a significant change in the patient�s clinical condition or care circumstances (such as development of co-morbidities or complications, deteriorating condition, illness/death of carer etc), that require a new GP Management Plan, Team Care Arrangements or review service. Where a service is provided in exceptional circumstances, the patient�s invoice or Medicare voucher (assignment of benefit form) should be annotated to briefly indicate the reason (e.g. clinically indicated, discharge, exceptional circumstances, significant change etc). If claims for payment in such circumstances are initially rejected they should be resubmitted for payment, ensuring that the reason is clearly identified.

4. MBS Item 721 � GP Management Plan (GPMP) To be eligible for a GPMP, a patient must have a chronic (or terminal) medical condition. Recommended frequency for a GPMP is once every two years, with regular reviews every six months. GPMPs involve the GP (who may be assisted by their practice nurse or others) assessing the patient, agreeing management goals, identifying patient actions, treatment and ongoing management and documenting this and a review date in the plan. GPMPs allow GPs to prepare care plans for eligible patients where the involvement of other health or care providers is not required. To be eligible for a GPMP, 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. The recommended frequency for a GPMP is once every two years, with regular reviews recommended every six months. This is not mandatory � in general, a new GPMP should not be prepared unless and until required by the patient�s condition, needs and circumstances A GPMP is required by legislation to be a comprehensive written plan that describes: - the patient�s health care needs, health problems and relevant conditions - management goals with which the patient agrees - actions to be taken by the patient - treatment and services the patient is likely to need - arrangements for providing these treatment and services - a date to review these matters. The GP may, with the permission of the patient, provide a copy of the GPMP or of relevant parts of the GPMP, to other providers involved in the patient�s care. The GP may be assisted by their practice nurse, Aboriginal health worker or other health professional in the GP�s medical practice or health service. This GP service is available to patients in the community.� It is also available to private in-patients (including private in-patients who are residents of aged care facilities) being discharged from hospital, where their usual GP (or a GP from the same practice) who prepares the GPMP is providing in-patient care; in this case the GPMP is claimed as an in-hospital service.� A GPMP is not available to public in-patients being discharged from hospital.� It is not available to residents of aged care facilities, except where they are private-in patients being discharged from hospital. To be eligible for a GPMP, 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. The recommended frequency for a GPMP is once every two years, with regular reviews recommended every six months. This is not mandatory � in general, a new GPMP should not be prepared unless and until required by the patient�s condition, needs and circumstances A GPMP is required by legislation to be a comprehensive written plan that describes: - the patient�s health care needs, health problems and relevant conditions - management goals with which the patient agrees - actions to be taken by the patient - treatment and services the patient is likely to need - arrangements for providing these treatment and services - a date to review these matters. The GP may, with the permission of the patient, provide a copy of the GPMP or of relevant parts of the GPMP, to other providers involved in the patient�s care. The GP may be assisted by their practice nurse, Aboriginal health worker or other health professional in the GP�s medical practice or health service. This GP service is available to patients in the community.� It is also available to private in-patients (including private in-patients who are residents of aged care facilities) being discharged from hospital, where their usual GP (or a GP from the same practice) who prepares the GPMP is providing in-patient care; in this case the GPMP is claimed as an in-hospital service.� A GPMP is not available to public in-patients being discharged from hospital.� It is not available to residents of aged care facilities, except where they are private-in patients being discharged from hospital.

5. MBS Item 723 � Team Care Arrangements (TCA) TCA are for patients with chronic or terminal medical conditions who require ongoing care from a multidisciplinary team. Whether or not a patient is eligible for TCA is essentially a matter for the GP to decide. Recommended frequency for a TCA is once every two years, with regular reviews every six months. TCA involve a GP (who may be assisted by a practice nurse), discussing/agreeing with the patient which providers should be involved, what information can be shared, collaborating with the participating providers on required treatments/services and documenting this and a review date in the patient�s plan. A GP can provide TCA without a GPMP. However, to be eligible for Medicare rebates for the five individual allied health services, a patient must be managed by a GP under both a GPMP and TCA. This item is for patients with a chronic or terminal medical condition who require ongoing care from a multidisciplinary team of their GP and at least two other health or care providers. Whether or not a patient is eligible for TCA is essentially a matter for the GP to decide. The recommended frequency for a TCA is once every two years, with regular reviews recommended every six months. This is not mandatory � in general, a new GPMP should not be prepared unless and until required by the patient�s condition, needs and circumstances TCA are required by legislation to include a document that describes: - treatment and service goals for the patient - treatment and services that collaborating providers will provide to the patient - actions to be taken by the patient - a date to review these matters. Each of the health or care providers must provide a different kind of ongoing care to the patient. A GP can coordinate team care and claim TCA without the need for a GPMP if the GP considers it appropriate. However, to be eligible for Medicare rebates for the five individual allied health services, a patient must be managed by a GP under both a GPMP and TCA (items 10950 to 10970 inclusive). It is not appropriate for allied health providers to provide part-completed referral forms to GPs for signature, particularly in a way that pre-empts the eligibility of the patient or the GP�s decision about the services required. This GP service is available to patients in the community and to private in-patients being discharged from hospital. This item is for patients with a chronic or terminal medical condition who require ongoing care from a multidisciplinary team of their GP and at least two other health or care providers. Whether or not a patient is eligible for TCA is essentially a matter for the GP to decide. The recommended frequency for a TCA is once every two years, with regular reviews recommended every six months. This is not mandatory � in general, a new GPMP should not be prepared unless and until required by the patient�s condition, needs and circumstances TCA are required by legislation to include a document that describes: - treatment and service goals for the patient - treatment and services that collaborating providers will provide to the patient - actions to be taken by the patient - a date to review these matters. Each of the health or care providers must provide a different kind of ongoing care to the patient. A GP can coordinate team care and claim TCA without the need for a GPMP if the GP considers it appropriate. However, to be eligible for Medicare rebates for the five individual allied health services, a patient must be managed by a GP under both a GPMP and TCA (items 10950 to 10970 inclusive). It is not appropriate for allied health providers to provide part-completed referral forms to GPs for signature, particularly in a way that pre-empts the eligibility of the patient or the GP�s decision about the services required. This GP service is available to patients in the community and to private in-patients being discharged from hospital.

6. MBS Items 725 and 727 � Reviews These items are for patients who have a current GPMP/TCA and require a review of their plan. Recommended frequency is once every six months or less if clinically required. A review of a GPMP/TCA involves the GP (who may be assisted by a Practice Nurse) reviewing the patient�s GPMP/TCA (in the case of a TCA, with the collaborating providers), documenting any relevant changes and setting the next review date. These items are for a GP to review a GP Management Plan and/or Team Care Arrangements. In general, a new GPMP/TCA should not be prepared unless and until required by the patient�s condition, needs and circumstances. The review items are the key components for assessing and managing the patient�s progress once a GPMP/TCA have been prepared. The recommended frequency is once every 6 months with a minimum claiming period of 3 months and provision for earlier claims in exceptional circumstances. A review is the principal mechanism for ensuring the continued appropriateness of the GPMP/TCA and the management of the patient�s chronic condition. It involves a systematic review of the patient�s progress against the GPMP/TCA goals by: reviewing the patient�s needs and goals, patient actions and treatment/services; making relevant changes to the documented GPM/TCA; and adding a new review date. Coordinating a review of a TCA must be conducted collaboratively with the other participating providers to establish the patient�s progress against the previously nominated treatment/service goals and agreeing on any necessary changes and on the specific treatment/services to be provided by each member of the team. A practice nurse, Aboriginal health worker or other health professional can assist a GP in preparing or reviewing a GPMP or TCA, for example, in assessing the patient, identifying the patient�s needs and making arrangements for services. The GP must review and confirm all assessments and elements of the service and must see the patient as part of the service. In general, GPs should choose to use the review item which is appropriate to the type of review being undertaken, i.e. item 725 for a review by a GP alone or item 727 for a team-based review, but not both at the same time.  These items are for a GP to review a GP Management Plan and/or Team Care Arrangements. In general, a new GPMP/TCA should not be prepared unless and until required by the patient�s condition, needs and circumstances. The review items are the key components for assessing and managing the patient�s progress once a GPMP/TCA have been prepared. The recommended frequency is once every 6 months with a minimum claiming period of 3 months and provision for earlier claims in exceptional circumstances. A review is the principal mechanism for ensuring the continued appropriateness of the GPMP/TCA and the management of the patient�s chronic condition. It involves a systematic review of the patient�s progress against the GPMP/TCA goals by: reviewing the patient�s needs and goals, patient actions and treatment/services; making relevant changes to the documented GPM/TCA; and adding a new review date. Coordinating a review of a TCA must be conducted collaboratively with the other participating providers to establish the patient�s progress against the previously nominated treatment/service goals and agreeing on any necessary changes and on the specific treatment/services to be provided by each member of the team. A practice nurse, Aboriginal health worker or other health professional can assist a GP in preparing or reviewing a GPMP or TCA, for example, in assessing the patient, identifying the patient�s needs and making arrangements for services. The GP must review and confirm all assessments and elements of the service and must see the patient as part of the service. In general, GPs should choose to use the review item which is appropriate to the type of review being undertaken, i.e. item 725 for a review by a GP alone or item 727 for a team-based review, but not both at the same time.

7. MBS Item 729 � GP contribution to care plans This item is for patients with a chronic medical condition who are having a multidisciplinary care plan prepared or reviewed for them by another health or care provider. Recommended frequency is once every six months. The contribution involves the GP (who may be assisted by their practice nurse or other) confirming the patient�s agreement for the GP to contribute to the plan, collaborating with the person preparing or reviewing the plan and including the GP�s contribution in the patient�s records. MBS item 729 is for patients with a chronic medical condition who are having a multidisciplinary care plan prepared or reviewed for them by another health or care provider (i.e. other then the usual GP). This can include contribution to hospital discharge plans for both private and public inpatients being discharged from hospital. (Item 731 should be used for patients who are residents of aged care facilities on discharge from hospital). MBS item 729 does not require an attendance with the patient - a GP can contribute on the basis of knowledge of the patient and their health and care needs. This can take place by telephone or in person at the invitation of the provider (e.g. discharge planner) developing the care plan. It involves: gaining or confirming the patient�s agreement for the GP to contribute; collaborating with the person preparing the care plan to set goals and specify treatment/services to be provided by the GP; adding a copy or note of the GP�s contribution to the plan (either the treatment/services to be provided by the GP or the GP�s advice to the person preparing the plan) to the patient�s records. This GP service is available to patients in the community and to public or private in-patients being discharged from hospital. It is not available to residents of aged care homes (see item 731).MBS item 729 is for patients with a chronic medical condition who are having a multidisciplinary care plan prepared or reviewed for them by another health or care provider (i.e. other then the usual GP). This can include contribution to hospital discharge plans for both private and public inpatients being discharged from hospital. (Item 731 should be used for patients who are residents of aged care facilities on discharge from hospital). MBS item 729 does not require an attendance with the patient - a GP can contribute on the basis of knowledge of the patient and their health and care needs. This can take place by telephone or in person at the invitation of the provider (e.g. discharge planner) developing the care plan. It involves: gaining or confirming the patient�s agreement for the GP to contribute; collaborating with the person preparing the care plan to set goals and specify treatment/services to be provided by the GP; adding a copy or note of the GP�s contribution to the plan (either the treatment/services to be provided by the GP or the GP�s advice to the person preparing the plan) to the patient�s records. This GP service is available to patients in the community and to public or private in-patients being discharged from hospital. It is not available to residents of aged care homes (see item 731).

8. MBS Item 731 � contribution to care plans for residents of aged care facilities This item is for a GP to contribute to a multidisciplinary care plan for a resident of an aged care facility at the request of the facility. Recommended frequency is once every six months. Where a GP has contributed to an aged care resident�s multidisciplinary care plan, the resident is eligible for Medicare rebates for up to five individual allied health services and eight type 2 diabetes group items each calendar year. - It is expected that the GP�s contribution to the resident's multidisciplinary care plan would be through direct collaboration with the aged care facility at the request of the facility. - MBS item 731 does not require an attendance with the patient - a GP can contribute on the basis of knowledge of the patient and the health and care needs. This can take place by telephone or in person at the invitation of the provider (e.g. aged care facility) developing the care plan. This service is similar to item 729 other than: It is only available to residents of aged care facilities; It can only be provided to an aged care resident where the multidisciplinary plan is being prepared by the aged care facility or by a hospital from which the resident is being discharged; A contribution to a care plan for an aged care resident must be at the request of the aged care facility or the discharging hospital; The GP�s contribution should be documented in the care plan maintained by the aged care facility or discharging hospital and a record included in the resident�s medical record. A rebate will not be paid within three months of a previous claim for the same item or within three months of a claim for other EPC CDM items. Where a resident�s GP has contributed to a care plan prepared by the aged care facility or discharging hospital, the resident is eligible to access rebates under the Medicare allied health items.- It is expected that the GP�s contribution to the resident's multidisciplinary care plan would be through direct collaboration with the aged care facility at the request of the facility. - MBS item 731 does not require an attendance with the patient - a GP can contribute on the basis of knowledge of the patient and the health and care needs. This can take place by telephone or in person at the invitation of the provider (e.g. aged care facility) developing the care plan. This service is similar to item 729 other than: It is only available to residents of aged care facilities; It can only be provided to an aged care resident where the multidisciplinary plan is being prepared by the aged care facility or by a hospital from which the resident is being discharged; A contribution to a care plan for an aged care resident must be at the request of the aged care facility or the discharging hospital; The GP�s contribution should be documented in the care plan maintained by the aged care facility or discharging hospital and a record included in the resident�s medical record. A rebate will not be paid within three months of a previous claim for the same item or within three months of a claim for other EPC CDM items. Where a resident�s GP has contributed to a care plan prepared by the aged care facility or discharging hospital, the resident is eligible to access rebates under the Medicare allied health items.

9. CDM Items and Service Incentive Payments * The GPMP item should not be claimed within 12 months of an asthma SIP, other than in exceptional circumstances. ** The asthma SIPs should not be claimed within 12 months of a GPMP, unless clinically indicated that a SIP is required, as opposed to ongoing management under the GPMP and review items, and normal consultation items. *** The SIP item and the CDM/TCA review items should not be claimed within three months of each other. The CDM items represent an important opportunity to improve chronic disease management through general practice. The items represent an alternative funding stream for best practice care for people with chronic medical conditions, including the conditions targeted by the SIPs. Service Incentive Payments (SIPs) for best practice care of patients with asthma and diabetes continue to be available. The asthma SIPs are based broadly on an assess/plan/review cycle which is similar to the process involved in the GPMP and review items. SIPs and GPMPs for management of asthma conditions should not both be claimed for the same patient at the same time. The diabetes SIP pays an incentive for the provision of care over the previous annual cycle, and does not duplicate planning for the patient�s care through a GPMP or TCA over the forward period.The CDM items represent an important opportunity to improve chronic disease management through general practice. The items represent an alternative funding stream for best practice care for people with chronic medical conditions, including the conditions targeted by the SIPs. Service Incentive Payments (SIPs) for best practice care of patients with asthma and diabetes continue to be available. The asthma SIPs are based broadly on an assess/plan/review cycle which is similar to the process involved in the GPMP and review items. SIPs and GPMPs for management of asthma conditions should not both be claimed for the same patient at the same time. The diabetes SIP pays an incentive for the provision of care over the previous annual cycle, and does not duplicate planning for the patient�s care through a GPMP or TCA over the forward period.

10. Advantages of CDM Items Easy to use with simple MBS requirements Enhanced role for practice nurses and AHWs GPMP is widely accessible for patients with chronic or terminal conditions GPs can prepare care plans without having to collaborate with other providers, but MBS funds collaboration where required CDM items involve simplified MBS requirements and more flexibility than old EPC multidisciplinary care plan items GPs can provide a GP Management Plan to patients with chronic or terminal conditions, without needing to collaborate with other care providers � more patients are eligible for GPMPs, within the broad definition of chronic medical condition GPs can collaborate with other providers if the patient has complex multidisciplinary care needs and would benefit from Team Care Arrangements. GPs can be assisted by their practice nurse, Aboriginal health worker or other health professional. Plans can be reviewed by the same GP, a GP from the same practice or, in the event that the patient has moved practices, by a GP from the new practice. GPs can choose most appropriate review item for circumstances of patient � GPMP review for GP review of a GPMP; Team Care review if coordinating review of a TCA with team input. CDM items involve simplified MBS requirements and more flexibility than old EPC multidisciplinary care plan items GPs can provide a GP Management Plan to patients with chronic or terminal conditions, without needing to collaborate with other care providers � more patients are eligible for GPMPs, within the broad definition of chronic medical condition GPs can collaborate with other providers if the patient has complex multidisciplinary care needs and would benefit from Team Care Arrangements. GPs can be assisted by their practice nurse, Aboriginal health worker or other health professional. Plans can be reviewed by the same GP, a GP from the same practice or, in the event that the patient has moved practices, by a GP from the new practice. GPs can choose most appropriate review item for circumstances of patient � GPMP review for GP review of a GPMP; Team Care review if coordinating review of a TCA with team input.

11. Advantages of CDM Items (cont) Flexibility in claiming frequency Access to allied health (individual and group) services GPs can prepare (for private patients) or contribute (public & private patients) to discharge plans, including for aged care residents The items support the use of templates, checklists and best practice models. CDM services can be claimed at recommended or minimum claiming intervals, or earlier in exceptional circumstances, depending on needs and circumstances of the patient. Patients can access MBS items 10950 � 10970 after their GP has completed their GP Management Plan and Team Care Arrangements or, after the GP has completed their contribution to an aged care resident�s care plan. GPs can be involved in discharge planning for eligible patients � preparing/coordinating for private patients, contributing for public and private patients. GPs can contribute to aged care facility care plans and also contribute to multidisciplinary discharge care plans for aged care residents (public or private patients) being discharged from hospital. The CDM items are well-suited to the voluntary use of best practice models and protocols for management of specific chronic diseases, including checklists and templates that can be made available in medical software products. CDM services can be claimed at recommended or minimum claiming intervals, or earlier in exceptional circumstances, depending on needs and circumstances of the patient. Patients can access MBS items 10950 � 10970 after their GP has completed their GP Management Plan and Team Care Arrangements or, after the GP has completed their contribution to an aged care resident�s care plan. GPs can be involved in discharge planning for eligible patients � preparing/coordinating for private patients, contributing for public and private patients. GPs can contribute to aged care facility care plans and also contribute to multidisciplinary discharge care plans for aged care residents (public or private patients) being discharged from hospital. The CDM items are well-suited to the voluntary use of best practice models and protocols for management of specific chronic diseases, including checklists and templates that can be made available in medical software products.

12. MBS Item 10997 � Practice Nurse & Aboriginal Health Worker monitoring & support This covers the provision of monitoring and support to people with a chronic disease by a practice nurse or registered Aboriginal health worker, on behalf of a GP. The item is available to people with a chronic disease who have a GPMP, TCA, or Multidisciplinary Care Plan. A maximum of 5 services can be claimed per patient per year. The item may be used to provide: Checks on clinical progress; Monitoring medication compliance; Self management advice; and Collection of information to support GP reviews of Care Plans. Item 10997 came into effect from 1 July 2007. It covers the provision of monitoring and support to people with a chronic disease by a practice nurse or registered Aboriginal health worker on behalf of a GP. The objective of the initiative is to better utilise practice nurses in chronic disease management, which will help free up GPs to spend more time with patients on complex care. It is aimed at improved access and outcomes for patients, particularly in areas of workforce shortage. The item is available to people with a chronic disease, who have a GPMP, TCA or Multidisciplinary Care Plan in place. It will assist patients who require access to ongoing care, frequently, for relatively routine treatment and ongoing monitoring and support between the more structured reviews of the care plan by the GP. The item is intended to provide sufficient flexibility for the provision of services appropriate for the patient�s care. Suitable services may include: Checks on clinical progress Monitoring medication compliance Self management advice Collection of information to support GP reviews of Care Plans. The item is claimed by the GP. In line with existing practice nurse and registered AHW items, the service is provided by the practice nurse or registered AHW on behalf of the GP.Item 10997 came into effect from 1 July 2007. It covers the provision of monitoring and support to people with a chronic disease by a practice nurse or registered Aboriginal health worker on behalf of a GP. The objective of the initiative is to better utilise practice nurses in chronic disease management, which will help free up GPs to spend more time with patients on complex care. It is aimed at improved access and outcomes for patients, particularly in areas of workforce shortage. The item is available to people with a chronic disease, who have a GPMP, TCA or Multidisciplinary Care Plan in place. It will assist patients who require access to ongoing care, frequently, for relatively routine treatment and ongoing monitoring and support between the more structured reviews of the care plan by the GP. The item is intended to provide sufficient flexibility for the provision of services appropriate for the patient�s care. Suitable services may include: Checks on clinical progress Monitoring medication compliance Self management advice Collection of information to support GP reviews of Care Plans. The item is claimed by the GP. In line with existing practice nurse and registered AHW items, the service is provided by the practice nurse or registered AHW on behalf of the GP.

13. MBS Items 10950 to 10970 - Allied health items These items are for patients who have both a GPMP and TCA in place (item 721 or 725; and item 723 or 727). Aged care residents can access allied health items where their GP contributes to their multidisciplinary care plan. The items provide access to five individual allied health services per calendar year (Medicare rebate of $48.95 per service). Under the CDM items access to Medicare rebates for certain allied health services is available for patients who are being managed under team-based multidisciplinary care. Team-based care incorporates a GP Management Plan and Team Care Arrangements, which together equate to an EPC multidisciplinary care plan. Most patients with multidisciplinary health care needs will be managed under team-based care, and most will have a GP Management Plan as first step. Patients continue to be eligible for the allied heath services while they are managed under team-based care � it is not necessary to have a new GP Management Plan and Team Care Arrangements prepared just in order to access a new round of allied health referrals. Aged care residents are eligible where their GP has contributed to the multidisciplinary care plan prepared by the aged care facility (or by the hospital for patients being discharged). Under the CDM items access to Medicare rebates for certain allied health services is available for patients who are being managed under team-based multidisciplinary care. Team-based care incorporates a GP Management Plan and Team Care Arrangements, which together equate to an EPC multidisciplinary care plan. Most patients with multidisciplinary health care needs will be managed under team-based care, and most will have a GP Management Plan as first step. Patients continue to be eligible for the allied heath services while they are managed under team-based care � it is not necessary to have a new GP Management Plan and Team Care Arrangements prepared just in order to access a new round of allied health referrals. Aged care residents are eligible where their GP has contributed to the multidisciplinary care plan prepared by the aged care facility (or by the hospital for patients being discharged).

14. MBS items 81100 to 81125 � Type 2 diabetes These items are for patients who have type 2 diabetes and have in place: A GPMP (item 721) or a review (item 725); or For aged care residents, a multidisciplinary care plan to which the GP has contributed (or contributed to its review) (item 731). They provide access to one assessment and up to eight group services (provided by a diabetes educator, exercise physiologist or dietitian) each calendar year. Patients with type 2 diabetes can receive a Medicare rebate for group services provided by eligible diabetes educators, exercise physiologists and dietitians, on referral from a GP. Before referring patients, the GP must put in place: A GPMP � item 721 (or review item 725); or For an aged care resident, the GP must have contributed to (or contributed to the review of), a care plan prepared by the facility (item 731). If the GP wants to refer the patient for individual allied health services under items 10950 to 10970, a TCA is also required. The GP is to refer the patient to an eligible diabetes educator, exercise physiologist or dietitian to conduct an individual assessment under items 81100, 81110 or 81120 to prepare the patient for an appropriate group services program. If the patient is assessed as suitable, they may then receive one assessment and up to eight group services each calendar year, delivered by either one type of allied health professional, or a combination of providers. This should be determined as part of the individual assessment. Patients with type 2 diabetes can receive a Medicare rebate for group services provided by eligible diabetes educators, exercise physiologists and dietitians, on referral from a GP. Before referring patients, the GP must put in place: A GPMP � item 721 (or review item 725); or For an aged care resident, the GP must have contributed to (or contributed to the review of), a care plan prepared by the facility (item 731). If the GP wants to refer the patient for individual allied health services under items 10950 to 10970, a TCA is also required. The GP is to refer the patient to an eligible diabetes educator, exercise physiologist or dietitian to conduct an individual assessment under items 81100, 81110 or 81120 to prepare the patient for an appropriate group services program. If the patient is assessed as suitable, they may then receive one assessment and up to eight group services each calendar year, delivered by either one type of allied health professional, or a combination of providers. This should be determined as part of the individual assessment.

15. MBS Item 713 � Type 2 diabetes risk evaluation The Council of Australian Governments (COAG) has announced a Type 2 Diabetes Prevention Program. The Commonwealth�s contribution to this agenda includes the introduction of a new Medicare Benefits Schedule (MBS) item number for people aged 40-49 years who are at high risk of developing type 2 diabetes. Subsidised Lifestyle Modification Programs will also be available for patients at high risk. Item 713 commenced on 1 July 2008. The Council of Australian Governments (COAG) has announced a Type 2 Diabetes Prevention Program. The Commonwealth�s contribution to this agenda includes the introduction of a new Medicare Benefits Schedule (MBS) item number for people aged 40-49 years who are at risk of developing type 2 diabetes and the introduction of subsidised Lifestyle Modification Programs (LMPs). The new item number commenced on 1 July 2008. It allows for eligible patients to be referred to a subsidised accredited LMP to prevent or delay the onset of Type 2 diabetes. Eligible patients can also be referred through the Age 45 Year Old Health Check (Item 717) or the Aboriginal and Torres Strait Islander Health Check (Item 710). As with other health checks, the role of the practice nurse and Aboriginal Health Worker is to support patient identification, information collection and information provision to patients. The Council of Australian Governments (COAG) has announced a Type 2 Diabetes Prevention Program. The Commonwealth�s contribution to this agenda includes the introduction of a new Medicare Benefits Schedule (MBS) item number for people aged 40-49 years who are at risk of developing type 2 diabetes and the introduction of subsidised Lifestyle Modification Programs (LMPs). The new item number commenced on 1 July 2008. It allows for eligible patients to be referred to a subsidised accredited LMP to prevent or delay the onset of Type 2 diabetes. Eligible patients can also be referred through the Age 45 Year Old Health Check (Item 717) or the Aboriginal and Torres Strait Islander Health Check (Item 710). As with other health checks, the role of the practice nurse and Aboriginal Health Worker is to support patient identification, information collection and information provision to patients.

16. Further information Key information is available at: www.health.gov.au (follow the A-Z index and �C� for �Chronic Disease Management�)