Table of Contents


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    Best-practice care for your chronically ill patients

    Is there any evidence that care planning makes a difference?

    The overwhelming evidence demonstrates that systematic, longitudinal planned care, in collaboration with the care team and with support for patient self-management, substantially improves outcome for chronically ill patients [see Sharing Healthcare Guidelines and Improving Chronic Illness Care].

    In Australia, this model of care is supported by GP Management Plans (GPMPs) and Team Care Arrangements (TCAs).  A GP can employ other systematic methods to manage their chronically ill patients.  However GPMPS and TCAs provide the only mechanism through which the GP’s effort will be fully remunerated.

    Which of my chronically ill patients should be receiving planned, collaborative care?

    Many GPs think that planned, collaborative care should only apply to chronically ill patients with severe complications. There is no evidence that this approach should be restricted only to patients with complications.  Indeed, Kaiser Permanente in the US showed that applying the collaborative care model to ALL their patients with coronary artery disease gave over 70% reduction in mortality [see Patient Health Status and Health-Related Quality of Life, Volume 35, Issue 5, Supplement, Pages S398-S406, November 2008].

    How many of my patients are eligible for a GP Management Plan or Team Care Arrangement?

    A typical full time GP in Australia has over 400 patients with a chronic disease. All these patients are eligible for a GP Management Plan and the vast majority are eligible for a Team Care Arrangement involving at least two other care providers.

    How much time does a typical GP spend with their chronically ill patients?

    The Australian Institute of Health and Welfare reports that 42% of all visits to a GP involve the management of a chronic condition.  In independent trials, cdmNet has more than doubled GP and practice nurse productivity in managing these patients.

    Benefits of cdmNet

    How easy is cdmNet to use?

    With just a few clicks of your mouse, cdmNet will upload the data from your GP software (Best Practice and Medical Director 3) and create an individualised, evidence-based care plan for your patient. A few more clicks and the plan and supporting documentation can be shared with the whole care team. Monitoring is automatic, so you always know how care providers and the patient are adhering to their care plan. Reviews and Annual Cycles of Care are also automated, so that they too can be completed and shared within minutes.

    Collaboration takes place seamlessly and effortlessly, because everything is shared automatically with the care team, the patient, and the GP. Because cdmNet manages the entire process, and not just one part of it, you will be able to spend more time with your patients, whilst at the same time minimising paper work, and maximising practice revenues.

    Does cdmNet save time?

    Independent trials of cdmNet conducted by Monash University and Deakin University showed that cdmNet can more than double practice productivity [see CDM-Net: A Broadband Health Network for Transforming Chronic Disease Management, Final Report, March, 2010].  cdmNet saves time by:

    • Guiding you seamlessly through the entire chronic disease management process
    • Within seconds, automatically preparing best practice GP Management Plans (GPMPs) that include comorbidities and are individualised to your patient’s needs
    • Automatically preparing Team Care Arrangements (TCAs) and distributing these to the care team, thereby avoiding faxing, scanning, and time consuming follow-up
    • Automatically tracking patient progress against the care plan, enabling you to review the progress of your patients
    • Automatically preparing GPMP and TCA Reviews, so that these can be completed on any patient visit within minutes

    Does cdmNet really eliminate paperwork?

    cdmNet eliminates most of the paperwork associated with chronic disease management and meeting Medicare requirements by:

    • Automatically producing, electronically signing, distributing and storing all documentation, including GPMPs, TCAs, Allied Health Referral Forms, Home Medicines Review Referrals, GPMP and TCA Reviews, and Annual Cycle of Care documents
    • Automatically sending SMS and email reminders and recalls to your patients for appointments and reviews
    • Completely eliminating the need to send faxes and letters to allied health and other members of the care team

    How does cdmNet help collaboration and team care?

    cdmNet enables everyone in the care team, including the patient, to have total visibility of relevant patient health data while removing the overhead of collaboration. cdmNet makes collaboration easy by:

    • In one click, generating and sharing TCAs and TCA Reviews with the care team and the patient
    • Automatically generating an Electronic Health Record that can be shared and updated by the care team and the patient
    • Monitoring and sharing progress notes and appointment details across the care team and with the patient
    • Enabling efficient electronic communication among the care team, reducing the need for faxes and follow up phone calls

    Does cdmNet improve patient compliance, safety and quality?

    cdmNet significantly improves the safety and quality of care by:

    • Bringing best practice guidelines to the point of care through individualised GPMPs and TCAs
    • Ensuring that appropriate allied health, specialist, and other healthcare services are included in GPMPs and TCAs
    • Ensuring that the entire care team has visibility of your patient’s health status, progress against the care plan, and appointments with other providers
    • Supporting patient self-management by providing patient-appropriate views of the care plan, reminding them to make planned appointments in a timely way, and enabling them to contribute to their health record and progress notes
    • Automatically alerting the GP and the care team of upcoming or overdue tasks, including GPMP and TCA Reviews and Annual Cycles of Care

    How does cdmNet increases Practice revenues?

    Regular users of cdmNet typically increase their net revenues from CDM items by over $35,000 annually.  cdmNet can substantially multiply net revenues from chronic disease management services by:

    • Greatly increasing the productivity of the practice, including both GPs and practice nurses
    • Allowing the practice to systematise the management of their entire chronic disease population, greatly increasing the number of Medicare CDM services provided across the practice
    • Alerting GPs and practice nurses whenever GPMP or TCA Reviews, Cycles of Care, and Home Medicines Reviews are due
    • Automating the generation of GPMP and TCA Reviews, so that they can be completed opportunistically on any patient visit
    • Enabling more patients to be on care plans, generating more Medicare CDM Items, Practice Nurse Incentive Payments, Practice Incentive Payments, and Service Incentive Payments for the practice

    How does cdmNet help with Medicare audit requirements?

    cdmNet tracks patient care and facilitates Medicare compliance by:

    • Guiding the GP and practice staff through the complex processes required to justify claims for Medicare CDM items
    • Ensuring that all Medicare process requirements are met
    • Supporting compliance with best practice guidelines, including timely review and follow up
    • Providing a complete audit trail of GP and care team activities
    • Through automatic patient reminders and tracking of patient appointments, assisting the GP to meet duty of care obligations

    Is cdmnet suitable for all types of GP practices?

    cdmNet works in most GP practice environments by:

    • Supporting any practice size, including solo practices, large practices, and superclinics
    • Supporting care management activities undertaken by practice nurses and GPs or GPs alone
    • Supporting any practice workflow, including systematic recall or ad hoc patient visits
    • Allowing access anywhere, anytime by all members of the care team, including the patient

    Does cdmNet keep adequate health records for my patients?

    cdmNet provides a collaborative space for storing and sharing care plans, health data, and progress information across the entire care team and with the patient.

    • cdmNet stores patient data securely for the legislated period of at least seven years, or longer if a child under 12 years of age
    • The health data of your patients is always accessible to you and the care team, anywhere, anytime, via login to the cdmNet web site
    • Copies of GPMPs, TCAs, Reviews and other health information can be downloaded and stored in local GP and provider systems, if desired

    Does cdmNet allow the patient to contribute to their care plan?

    cdmNet enables the patients to contribute to their own care plan by:

    • Allowing patients to add their own measurements of blood pressure, weight and blood glucose
    • Enabling patients to enter their own appointments with allied health providers,  as well as adding progress notes for review by the care team.

    What is the evidence that cdmNet works?

    For patients with chronic disease, the Royal Australian College of General Practitioners (RACGP) recommends that patients receive planned, systematic care, in collaboration with a care team and the patient. The RACGP also recommends that patients be continuously monitored and followed up and helped to manage their own care [http://www.racgp.org.au/guidelines/sharinghealthcare].

    Independent trials of cdmNet by Monash University and Deakin University showed that GPs and practice nurses who used cdmNet were two to three times more productive in providing Chronic Disease Management (CDM) services than they were before using cdmNet [see CDM-Net: A Broadband Health Network for Transforming Chronic Disease Management, Final Report, March, 2010].  This means that busy practices can provide more CDM services while also saving time to focus on the immediate concerns of their patients.

    The trials also showed collaboration with the care team using Team Care Arrangements increased three fold, while reviews of GP Management Plans and Team Care Arrangements increased five fold.

    Quality of care also increased as measured by adherence to best practice guidelines.  For example, use of dietician services increased by 1600%, podiatry services by 250%, and home medicines reviews by 500%.

    Either with a practice nurse or as a sole practitioner, cdmNet enables a systematic evidence-based approach to the management of the practice’s population of chronically ill patients while reducing the workload on GPs and practice nurses.

    Remuneration and costs

    How much can I earn from MBS Chronic Disease Management Items?

    Currently, a typical GP earns about $15,000 from Medicare CDM Items per year.  If a GP takes a best-practice population-based approach to all their chronically ill patients, they can earn over $100,000 per annum for MBS CDM Items 721, 723, and 732, as well as practice nurse incentives Item 10997 payments of over $30,000.   In addition, practice and service incentive payments could add a further $10,000, making a total of more than $140,000 per GP per year.

    While these are very large earnings, the delivery of these services in a busy practice setting is simply not  possible without cdmNet as an integral part of your chronic disease management process.

    How much does cdmNet cost?

    cdmNet provides a range of free services for all health care providers and patients, including a shared electronic health record (controlled by the patient in collaboration with the GP) and support for patient self-management.

    However, to continue to provide cdmNet services equally to all Australians with chronic illness, Precedence Health Care charges a fee to GPs for some additional services, including certain CDM services.  These additional services and the fees charged are shown in the table below.

    MBS CDM Item 721
    (GPMP)
    723
    (TCA)
    732
    (GPMP Review)
    732
    (TCA Review)
    Diabetes
    ACoC
    900
    (HMR)
    MBS Rebate* $144.24 $114.30 $72.05 $72.05 $40.00 $154.80
    cdmNet Fee* $17.50 $17.50 $10.00 $10.00 $5.00 $5.00
    Net Revenue to GP  $126.74 $96.80 $62.05 $62.05 $35.00 $149.80

    * MBS incentive payments and rebates may change from time to time in accordance with Government published rates. Precedence reserves the right to change the chargeable cdmNet transactions and fees from time to time. Members will be notified at login to cdmNet of any such changes in fees 30 days prior to the new fees taking effect.
    † Charged on referral to Pharmacist.

    How much can I realistically earn using cdmNet to help me manage my chronically ill patients?

    Based on independent University trials, the use of cdmNet has been shown to increase net GP earnings per year from MBS CDM Items from an average $15,000 per year to over $50,000 per year, after subtracting fees paid for cdmNet services and practice nurse costs [see CDM-Net: A Broadband Health Network for Transforming Chronic Disease Management, Final Report, March, 2010].   These improvements were achieved without any increase in the amount of time GPs and practice nurses spent on providing these services.  If the practice is organised to treat all its chronically ill patients according to RACGP guidelines, cdmNet can increase net earnings per GP by over $100,000 per year.

    Medicare CDM Items

    Medicare Items and their requirements are frequently updated by Medicare.  While we aim to keep these notes current, for the latest information please visit the Department of Health website at www.health.gov.au/mbsprimarycareitems for the most current information.   For further information you can email Medicare on mbsonline@health.gov.au or call 132 150.

    What is a General Practitioner Management Plan (GPMP) – MBS Item 721?

    To be eligible for a GPMP a patient must have a chronic (or terminal) medical condition that has been or is likely to be present for 6 months or longer.

    A ‘chronic medical condition’ is one that has been or is likely to be present for at least six months, including but not limited to asthma, cancer, cardiovascular disease, diabetes mellitus, musculoskeletal conditions and stroke.

    THE GPMP is a comprehensive written plan that describes:

    • The patient’s health care needs, 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 treatments and services
    • A date to review these matters.

    The recommended frequency of GPMP is once every two years, with regular reviews recommended every 6 months.

    GPMPs allow GPs to prepare care plans for their patients where the involvement of other health care providers is not required. If other health or care providers are required, the patient will require a Team Care Arrangement (TCA).

    What is a Team Care Arrangement (TCA) – MBS Item 723?

    A TCA is for patients with a chronic or terminal medical condition who require ongoing care from a multidisciplinary team or their GP and at least two other health or care providers.

    The recommended frequency for a TCA is once every two years with regular reviews recommended every 6 months. A TCA is a document that describes:

    • The 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 that reviews these matters

    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.

    What is a GPMP / TCA review – MBS Item 732?

    A new GPMP / TCCA should not be prepared 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 has been prepared.

    The recommended frequency is once every 6 months with a minimum claiming period of 3 months , with provision for earlier claims in exceptional circumstances.

    A review is the principle mechanism for ensuring the continued appropriateness of the GPMP/TCA and the management of the chronic condition. It involves a systematic review of the patient’s progress against the GMPM/TCA goals by:

    • Reviewing the patient’s needs and goals, patient actions and treatment/services;
    • Making relevant changes to the documented GPMP/TCA, and
    • Adding a new review date

    NOTE: A GP can claim for both a GPMP Review and TCA Review on the same day (i.e., two MBS items 732), providing both are delivered on the same day and are undertaken according to MBS requirements

    Is there a Medicare rebate for nurses involved in care management?

    MBS item 10997 enables nurses and Aboriginal Health Workers to support patients that have a GPMP and TCA for services such as:

    • Checks on clinical progress
    • monitoring medication compliance
    • Self-management advice, and
    • Collection of information to support GP reviews of GPMPs and TCAs

    The Medicare rebate for item 10997 is paid at 100% of the schedule fee, which is $11.55.  A maximum of 5 visits per patient per calendar year can be claimed.