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GP CARE PLANS

 

Australian GPs are encouraged to structure chronic disease management (CDM) utilising specific Medicare item numbers*. A ‘chronic medical condition’ is defined as a condition that has been, or is likely to be, present for at least six months.  GPs can be assisted by practice nurses, Aboriginal and Torres Strait Islander health practitioners, Aboriginal health workers, and other health professionals in preparing and reviewing the CDM items. 

 

The CDM items are useful tools for improving the care of epilepsy, however, many GPs do not think of including epilepsy in their routine CDM activities.

 

In epilepsy, preparation of a GP Management Plan (GPMP -Item 721) allows the patient’s regular GP to summarise past care and set treatment goals with the patient. The plan can inform and guide all practice staff caring for the patient. Item 731 can be utilised in a Residential Aged Care Facility (RACF).

 

Utilising the practice nurse to open the epilepsy GPMP, sumarising all relevant epilepsy  history and information, is an excellent way to create the initial document. As the practice nurse gains knowledge about the individual's epilepsy s/he will be prepared to offer patient support through item 10997. 

 

Team Care Arrangements (TCA – Item 723) promote interaction with a range of support services (see CDM Q&A). A TCA can include non-health workers; where they are contributing to the plan and not simply providing a service identified in the plan. Team members may be community service or education providers, such as ‘meals on wheels’ staff, personal care workers, teachers, or probation officers.  Similarly, persons such as a Workcover Rehabilitation Case Manager, fitness instructor, or personal trainer could be members of a TCA team if they are contributing to the plan. This could be of assistance to an epilepsy patient who has social, educational or employment issues to be addressed in their care. Epilepsy educators are available in all states.

 

 

Review of a GPMP or TCA (Item 732) provides the opportunity for ongoing review of the plan and TCA. You can use the patient 'to do' list in the clinical software to prompt oppotunistic reviews, and have the reveiw template built into the plan.

 

 

Item 10997 allows the practice nurse to provide additional monitoring and support to a patient who has a GP Management Plan (721), a Team Care Arrangement  (TCA, 723) or a Multidisciplinary Care Plan (items 731) up to 5 times each calendar year. Item 10997 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.

 

 

Patients should be encouraged to make their epilepsy appointments with the same GP where possible. Most epilepsy appointments are not urgent and, with planning, continuity of care can be improved.

 

A pdf example template for epilepsy GPMP content is provided.  If you have suggestions regarding the template please email Rosemary. If you need an RTF format for direct upload into clinical software please make contact

 

Example template 

PDF Link