Chronic disease management care plans

Chronic Disease Management Care Plans are an effective way of ensuring people with long-term health issues are properly looked after.

Enhancing care

Chronic and terminally ill patients in Australia can benefit from a coordinated and goal-oriented approach to their health care via a Chronic Disease Management (CDM) Care Plan.

The plans, formerly known as Enhanced Primary Care or EPC, are developed in conjunction with the patient’s general practitioner and outline a person’s chronic medical conditions, management goals, and the actions needed to achieve these goals.

“Chronic disease management under a Medicare plan is intended to improve the standard and coordination of health care for people with chronic or terminal medical conditions who have complex care needs,” explains Brisbane based GP, Dr Richard Triggs.

Who is eligible?

It’s dependent on their GP’s clinical judgment to determine whether someone is eligible for a care plan.

The GP takes many factors into consideration including the patient’s medical condition and care needs, as well as the chronic nature of the condition. For the purpose of a management plan, this means a chronic condition that has been, or is likely to affect someone for more than six months.

The Australian Government Department of Health website explains there is no specific list of conditions for someone to be eligible for a management plan. A few examples include cancer, cardiovascular disease, asthma, diabetes, musculoskeletal conditions (such as osteoarthritis or rheumatoid arthritis) and stroke.

Team players

Dr Triggs says in the majority of cases, a GP will draw up a CDM Care Plan with a patient who requires a multi-disciplinary approach to their health care.

The initial plan, he explains, can form the basis for a Team Care Arrangement (TCA), which is coordinated by the patient’s GP and allows the patient to access Medicare funding.

“It involves your GP talking with at least two other health care providers with respect to your chronic disease management,” Dr Triggs says.

Patients with a TCA are then able to access funding for appointments with allied health professionals, such as physiotherapists and podiatrists.

The key to being entitled to a TCA is that your GP will need to correspond with two other care providers, including specialists and/or allied health professionals, prior to the TCA being completed.

What does it all mean?

Put simply: if you have a chronic or terminal health condition, support is available from your GP to set goals to manage and in some cases improve your condition.

Dr Triggs offers the example of a person with diabetes, who may, in conjunction with the GP, set the goals to lose weight, lower their blood pressure and control their blood sugar levels. This information forms the CDM Care Plan.

“The TCA is the add-on, to help achieve the shared goals of the patient and doctor,” he says.

Once complete, the TCA enables the patient to some Medicare funding for appointments with the allied health providers who will best advise and support the achievement of those goals.

In the case of a patient with diabetes, Dr Triggs says dieticians, exercise physiologists, optometrists and podiatrists often form part of the multi-disciplinary team, working to ensure the best possible health outcomes for the individual.

And that is really what a Chronic Disease Management Plan and its possible add-on of a TCA are all about. It’s ensuring that all people with conditions that affect their long-term health, are being looked after in the best and most effective way possible.

Category: Health


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Article by: Defence Health