9 Creating Care Plans

As a Primary Care Provider or a Care Plan Creator, you can create care plans for patients.

Creating a care plan for a patient is a two-step process. You have to:

For information about creating a health record for a patient, see Chapter 4.1 Creating a Patient’s Health Record.

Some conditions are initially ticked if they are matched against the Current History section of the Health Summary. You can tick or untick any conditions you want to include or exclude from the care plan. You can also add a custom condition to the care plan by clicking Add Custom Condition... and selecting or entering the condition accordingly. Note that if you add a custom condition, cdmNet will not generate any goals or tasks specific to that condition automatically, so you may need to add custom goals and tasks on the Planning page if you see fit (see Chapter 4.2.4.1Adding Goals and Tasks).

Once you have selected the conditions you want the care plan to cover, cdmNet generates a proposed care plan for you, based on the patient’s information. A newly-created care plan looks like this.

If you made a mistake in creating the care plan or the patient develops a new chronic disease at any stage of the GP Management Plan lifecycle, you can modify the care plan, and repeat the automatic generation process, by clicking Rebuild Care Plan and making the appropriate changes.

The Planning and Care Team Pages become available once you have created a care plan for the patient.

You should review the care plan that cdmNet has generated to ensure that it meets the level of care that you believe is appropriate for the patient. It is up to your discretion to modify the care plan according to the patient’s needs (see Chapter 4.2.4.1 Adding Goals and Tasks).

In addition to generating a proposed care plan, cdmNet automatically assigns providers to tasks and adds them to the patient’s care team based on your Preferred Providers preferences (see chapter 7.5 Preferred Providers). You can review the care team members by visiting the Care Team page (see Figure 25). You can remove particular care team members if you see fit to do so, but note that any member that you remove may leave tasks unassigned, so you should return to the Planning page and review the changes after you have done so.

Once you are happy with the care plan and the care team members associated with it, click Approve GPMP.

Before approving your GPMP, you can set the dates for the next review and annual cycle of care (if the patient has Diabetes[†]).

You may get a yellow warning box indicating tasks on the care that do not have providers. It is recommended (but not required) that all tasks have assigned providers.

You should ensure that the dates of any GPMPs, TCAs, reviews and ACoCs you conduct using cdmNet are in accordance with Medicare rules for frequency of the relevant MBS items. In some cases, cdmNet warns you if it notices that you have set two of these items to occur closer together than Medicare guidelines suggest, but you are responsible for making the ultimate clinical decision as to what is most appropriate for the care of your patients.

If you ticked ‘Create and distribute a Team Care Arrangement’ (or subsequently click Create and Distribute TCA), cdmNet notifies the care team members that you have proposed a TCA for the patient.

If you are the Primary Care Provider or a Care Plan Creator, the patient then appears as below on your patient list.

To care team members, the same patient appears as below on the patient list.

If you did not tick the TCA box, cdmNet still notifies your care team that a GPMP exists and prompts them to log in and review it. You can create and distribute a Team Care Arrangement at any later time by clicking Create and Distribute TCA when you see fit.

Once you have approved a GP Management Plan, you can view and download a PDF file corresponding to MBS Item 721 from the Documents page.

You can also view and download the current Care Plan and Patient Summary.

If at any time you feel that it is necessary to start a new GPMP for the patient, you can click Restart GPMP Sequence. The previous care plan is superseded and a new care plan can be implemented. The ‘Valid from’ date changes to the current date and the next review and ACoC dates change accordingly.

Once a Team Care Arrangement has been created and cdmNet has notified the care team members, it is up to them to agree to it.

A minimum of two agreements is required in order to continue to the next stage.

While it is recommended that all care team members agree to the TCA independently, you can agree to their part in the agreement on their behalf, provided that you have consulted with them about it. To do this, click Add Agreement and tick the box to confirm that you have consulted with the provider.

Once you have enough agreements from your Care Team Members, you can approve the TCA by clicking Approve TCA. (If you are a Care Plan Creator, this allows you to approve the TCA on behalf of the Primary Care Provider.)

As a PCP or CPC, you need to determine how many services the Allied Health Providers can provide the patient per year. As per Medicare rules, up to 5 services may be provided unless the circumstances allow otherwise. You may select the following year to which the services may be applied.

Note that you can only electronically sign the Allied Health Referral Forms if you are the Primary Care Provider.

Once you have approved the TCA, PDF files for MBS item 723 and supporting documents (Allied Health Forms) become available in the Documents page.

As a PCP or CPC, it is up to you to review the GPMP when the review date approaches.

If a patient’s GPMP is nearing the review date, on your patient list under the Review Status, the status reads GPMP Review Approaching.

While you can review the GPMP when it is overdue, it is recommended to commence the GPMP review when the Commence GPMP Review link becomes available on a patient’s record (this is approximately one month before the review date that was set when the GPMP was approved).

This is a good point to review the patient’s progress while making modifications to the care plan if appropriate (by entering new tasks and goals onto the Planning page or clicking Rebuild Care Plan to get cdmNet to generate any proposed changes to the care plan for you).

Clicking Commence GPMP Review initiates the review process, displaying a screen where you can quickly review whether all tasks in the care plan were completed, as well as recording any measurements that are needed.

Once the GPMP review has been initiated, it is up to the PCP or CPC to approve it. (You may need to adjust the review date and ACoC in order to comply with the Medicare rules.)

When the GPMP Review has been approved, the GP Management Plan Review form 732 becomes available in the Approved Care Plans section of the patient’s Documents Page.

If you have previously prepared a Team Care Arrangement for the patient, and you tick ‘Create and distribute a review of the Team Care Arrangement’ when approving the GPMP review, cdmNet notifies the care team that a TCA Review has commenced and needs their agreement.

As with TCAs, the TCA Review also needs a minimum of two agreements from care team members in order to continue. This time, however, cdmNet shows the agreements with another grey hand with thumbs up and a green tick.

Once two care team members have agreed to the TCA Review, you can approve it (as the PCP or CPC).

If you have not already generated Allied Health referral forms for the current year, you are prompted to do so when approving the TCA Review. It is up to your discretion to allocate the number of services that Allied Health members can provide to the patient, applicable to the current or following year.

When the TCA Review has been approved, the Team Care Arrangement Review form 732 is available on the patient’s Documents Page.

At the time of writing, cdmNet supports the Annual Cycle of Care for Diabetes only.

You can view the current progress against the ACoC by clicking Annual Cycle of Care in the top section of the page when viewing a patient’s health record. This opens a new window displaying the information in a PDF file.

The information presented in the ACoC is based on the progress of the patient’s care plan. cdmNet automatically calculates appropriate dates to include in the ACoC corresponding to the history of appointments and measurements shown on the Planning page.

You can approve an ACoC within a month of the ’Next Annual Cycle of Care’ date by clicking Approve ACoC.

A yellow warning box appears if there are areas in the ACoC that may not meet the Medicare minimum frequency requirements.

Should you have any further questions about using cdmNet or how it works, please contact our Support team by visiting http://cdm.net.au/help.