1 An
Introduction
The aim of this document is to help GPs and practice nurses
effectively use Precedence Health Care’s Chronic Disease Management
Network (cdmNet) to maximise the benefits to patients and to the practice.
cdmNet provides the following benefits to healthcare
providers and patients:
- Evidence
shows that properly personalised and well-managed care plans can significantly
improve health outcomes for patients with chronic disease.
- Individual
accounts that provide faster and easier creation of best practice GP Management
Plans (GPMPs), Team Care Arrangements (TCAs), and GPMP and TCA Reviews.
- Automation
and streamlining of documentation and MBS CDM compliance processes.
- Higher
quality care plans using best-practice guidelines and personalised to patient
needs.
- Improved
health outcomes for patients resulting from use of best practice personalised
care plans and tracking of patient actions to ensure compliance with management
goals.
- Improved
sharing of information and continuity of care across the care team and with the
patient through the cdmNet web portal.
- Improved
communication and coordination between the GP and other care team members
facilitated through the use of email, SMS, and the cdmNet web portal.
- Increased
practice revenues through increased throughput of MBS to Chronic Disease
Management (CDM) items and Practice Incentive Payments (PIP).
- Further
incentives for Home Medication Reviews, which are recommended for many patients
with chronic disease and complex conditions.
- ‘Duty
of care’ and compliance support for GPs and other providers through
automated reminders and alerts to patients and the care team.
- Greater
visibility of the care planning process through the provision of reports and
summaries detailing current care plan status and health outcomes for all
patients.
- All
patients on a care plan are regularly reviewed and the results of reviews are
shared with the care team.
- cdmNet
can be used either directly by a GP or in collaboration with a practice
nurse.
- cdmNet
also allows the patient to track their own care plan and provides reminder and
alert services to help the patient adhere to this
plan.
cdmNet is available for people with the following chronic
diseases, either singularly or as comorbidities:
- Asthma
- Chronic
Heart Failure
- Chronic
Kidney Disease
- Chronic
Low Back Pain
- Chronic
Obstructive Pulmonary Disease
- Coronary
Heart Disease
- Depression
(as a comorbidity)
- Diabetes
Mellitus Type I
- Diabetes
Mellitus Type II
- Osteoarthritis
- Stroke
It
is also possible to create customised care plans for any chronic disease or
complex condition.
1.1 Your
Role
As a registered provider, you could have one or more of the
following three roles, depending on your association with a particular
patient:
- A
Primary Care Provider (or PCP) – this is usually GPs and Nurse
Practitioners;
- A
Care Plan Creator (or CPC) – this can be any speciality; or
- Care
Team Member – this can be any
speciality.
If you are a Primary Care Provider or a Care Plan Creator,
you have more ability to modify patient information and care plans.
If you are a Care Team Member, you may only be able to view
information about patients and edit limited information about a patient’s
care plan.
