Chronic Disease Management

sep-iconGP Management Plans

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This is a comprehensive document that sets out and enables evidence-based management of your chronic health and care needs. A chronic condition is deemed to be one that you have, or will have, for more than 6 months. This plan is done once every two years, with regular reviews of your progress against the plan, and it is direct billed to Medicare. The most common chronic diseases are: diabetes, asthma, emphysema, coronary heart disease, cancer of any type, osteoporosis and arthritis.

The plan involves you meeting with the practice nurse first, for about 30 mins, to discuss your medical condition/s and work with you to set goals and tasks to meet these goals. You will then see the doctor to complete the plan and look at what you have identified as to medical problems and goals. You will receive a copy of this plan for your records. The doctor will want to see you in 6 months time to review the goals and tasks and discuss any issues you have about the plan.

sep-iconTeam Care Arrangements

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This item is for patients with a chronic or terminal medical condition and who might require ongoing care from a team approach, which involves the GP and at least two other health care providers, such as a specialist, physiotherapist, dietitian, chiropractor or podiatrist.

Once your usual GP (or a GP in the same practice) has coordinated the development of Team Care Arrangement by completing the relevant requirements, a rebate can be claimed through Medicare for Allied Health services. Sometimes the allied health provider will direct bill Medicare for the treatment provided, so you have no out of pocket costs. (talk to the practice staff to identify if your allied health person has out of pocket costs).

The service must include a personal attendance by the GP with you, but may be assisted by the practice nurse, Aboriginal Health Worker or other health professional in the medical practice or health service.

sep-iconAccess to Allied Health Services

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The following groups of allied health professionals are eligible to provide services under Medicare for patients with a chronic condition and complex care needs and must be registered with Medicare Australia. Some of these are; Aboriginal Health Workers; Audiologists; Chiropractors; Osteopaths; Podiatrists; Diabetes Educators; Dietitians; Exercise Physiologists; Mental Health Workers; Occupational Therapists; Physiotherapists; Psychologists; Speech Pathologists.

If you wish to seek Medicare rebates for allied health services, you will need to have a Referral form for chronic disease allied health (individual) services under Medicare signed by your GP. If there is any doubt about your eligibility, a staff member can contact Medicare Australia to confirm the number of allied health services already claimed by you during the calendar year.

Medicare benefits are available for up to five (5) allied health services per eligible patient, per calendar year. These five allied health services can be made up of one type of service (eg five physiotherapy services) or a combination of different types of services (eg one dietitian and four podiatry services).

sep-iconMental Health Treatment Plan

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The GP Mental Health Treatment Plans are for patients with a mental disorder who would benefit from a structured approach to the management of their treatment needs. Mental disorder is a term used to describe a range of clinically diagnosable disorders that significantly interfere with an individual thinking, behavior, socialisation and emotions. These disorders can vary from stress and minor depression to conditions such as bipolar and schizophrenia.

The treatment plan involves a discussion between your doctor and you regarding assessment, your needs, goals and actions, referrals and required treatment/services, and review date. You or your doctor might suggest a referral to any of the following services; a psychiatrist; clinical psychologist, an appropriately trained GP or allied mental health professional for further management of your disorder.

Medicare benefits are available for up to twelve (12) mental health services per eligible patient, per calendar year, to help with the cost of attending these health professionals.