Chronic Disease Management

Chronic disease management (CDM) in general practice involves appropriate prevention, early identification and best practice management strategies.

This page contains resources for all members of the general practice team involved in chronic disease management.

The Division offers support to GPs, practice nurses and practice staff in all aspects of chronic disease management through practice visits, phone support, resource provision and continuing professional development activities focusing on a coordinated team based approach.

With nursing in general practice being one of the fastest growing areas in the profession of nursing many practices are employing nurses to the chronic disease management role and establishing nurse led chronic disease clinics.

Australian and international research highlights a range of benefits that nurses and nurse led chronic disease clinics can bring to general practice. These include improved health outcomes in chronic disease, assistance in primary acute care integration, better coordination of care, increased workforce capacity, the provision of practical and professional support to GPs, and the enhancement in the range of services available to people attending the practice.

Employment of Practice Nurses in chronic disease management (CDM) and use of a team approach (GP, Practice Nurse, administrative staff) to CDM improves patient care and outcomes and reduces GP workload. Clinics can improve patient review and recall process and make more efficient use of practice resources in delivery of care to patients with chronic disease, and facilitate linkages with specialist services.

Clinics can also contribute to the long term viability of the practice through increased use of the PIP and SIP items and General Practice Management Plans (GPMPs) and Team Care Arrangements (TCAs).

Regular clinic reviews can support and maintain patient self-management behaviours, and patient satisfaction can increase from having their needs met and having adequate time to discuss issues related to their chronic disease.

For more information please do not hesitate to contact the Ararat office p: 03 5352 4804 f: 03 5352 5495

Chronic Disease Management Resources

CDM Questions and Answers Booklet 2010 - DoHA

Changes to MBS items from May 2010

Australian Doctor Quick Reference Guide to MBS changes

Templates including instructions for importing templates

Health Assessments and Chronic Disease Management Flow Chart - Moreton Bay

GP Management Plan / Team Care Arrangement Flow Chart - Ballarat Division

Chronic Disease individual Allied Health services under Medicare

Practice Nurse buisness case calculator

Referral form for Allied Health services

Referral form for Dental services

75 years and older health check

Fact Sheet

40 - 49 years with high risk of developing type 2 diabetes Health Assessment

Fact Sheet

Sample Template

45 - 49 years with high risk of developing chronic disease Health Assessment

Fact Sheet

Guide to implementing the 45 - 49 year old health check

RACGP resources, includes: Check Lists, Templates letters to patients

RACGP SNAP: A Population Health Guide to Behavioural Risk Factors in General Practice. (SNAP = quit Smoking, better Nutrition, moderate Alcohol, Physical activity)

RACGP - Organisational issues for consideration, includes: Identifying eligible patients Patient’s readiness to change Referrals

The Red Book: RACGP guidelines for preventive activities in general practice (6th Edition 2005)

The Green Book: RACGP Putting Prevention into Practice

Healthy Kids Check

Fact Sheet

Sample Template

Comprehensive Medical Assessment (CMA)

Fact Sheet

Refugee and other humanitarian Health Assessment

Fact Sheet

Sample Template

Intellectual Disability Health Assessment

Fact Sheet

Aboriginal and Torres Strait Islander Health Assessment

Fact Sheet

Chronic Disease Management Medicare Items

Fact Sheet

Sample Templates:

GP Management Plan (Item 721)

GP Management Plan with prompts

Team Care Arrangement (Item 723)

Team Care Arrangement cover letter

Team Care Arrangements with prompts Combined GP Management Plan / Team Care Arrangement

Asthma

Childhood Disability

GP Management Plan / Team Care Arrangement

Coronary Heart Disease

Depression / Anxiety

Diabetes

Osteoathritis

Osteoporosis

GP Management Plan

Osteoporosis Information Sheet

Team Care Arrangement

Palliative Care