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Chronic Disease Management
Asthma
The Asthma Cycle of Care has replaced the Asthma 3+ Visit Plan.
An Asthma Cycle of Care includes at least two asthma related consultations within 12months for a patient with moderate to severe asthma noting that the review visit must be planned. To complete an Asthma Cycle of Care you must:
1. Document diagnosis and assessment of asthma severity and level of asthma control.
2. Review the patients use of, and access to, asthma related medication and devices.
3. Provide a written asthma action plan (or documented alternative if the patient is unable to use a written action plan).
4. Provide asthma self-management education
5. Review the written or documented asthma action plan.
( for a greater detail of the above steps please utilise links below for Completing the Asthma Cycle of Care - A guide for General Practitioners.)
Practice signon payment
To sign on to receive Asthma Cycle of Care payments contact Medicare Australia PIP enquiry line on 1 800 222 032 for an application form. There is a one off payment for registering. If your practice originally registered for Asthma 3+ Visit Plan this automatically carries over to Asthma Cycle of Care.
Claiming your Asthma Service Incentive Payment (SIP)
You must meet the Asthma Cycle of Care requirements in a minimum of 2 visits (within a 12month period)
All visits should be billed under the normal attendance items with the exception of the visit that completes the Asthma Cycle of Care, then claim using appropriate Medicare item number as listed below:
GENERAL PRACTITIONER ATTENDANCE
Level B Surgery Consultation 2546
Level B Out-of-Surgery Consultation 2547
Level C Surgery Consultation 2552
Level C Out-of-Surgery Consultation 2553
Level D Surgery Consultation 2558
Level D Out-of-Surgery Consultation 2559
OTHER NON-REFERRED ATTENDANCES
Surgery Consultations
Standard Consultation 2664
Long Consultation 2666
Prolonged Consultation 2668
Out-of-surgery Consultations
Standard Consultation 2673
Long Consultation 2675
Prolonged Consultation 2677
Alternative asthma care using MBS Chronic Disease Management items
The Chronic Disease Management (CDM) items provide an alternative funding mechanism to the SIPs for providing best practice care of patients with chronic conditions, including patients with asthma. For patients with asthma alone a GP should choose to use either GP managed care through the CDM items (GP Management PlanGPMP), or provide an Asthma Cycle of Care, but not both services for the same patient as the work involved in both services overlaps (these items should not both be claimed in the same twelve months). For patients with asthma and complex needs requiring care from a multidisciplinary team, a GP may provide
team-based care using the CDM items (for most patients this means a GPMP and a Team Care ArrangementsTCA), and the Asthma Cycle of Care. A CDM review item and an Asthma Cycle of Care should not be claimed within three months of each other as the work involved overlaps.
More detailed information on the CDM items is available from Medicare Australia on 132 150 or in the Medicare Benefits Schedule Book.
Associated Links:
Asthma Cycle of Care general information
http://www.health.gov.au/internet/wcms/publishing.nsf/content/phd-asthma-cycle
Completing the Asthma Cycle of Care- A guide for General Practitioners.
http://www.health.gov.au/internet/wcms/publishing.nsf/content/2C0145E57692CBFBCA257242001BFE66/$File/a4-sheet.pdf
Spirometer Guide from National Asthma Council
http://www.nationalasthma.org.au/html/management/spiro_guide/sp_gd003.asp
Asthma Management Handbook (Revised & Updated 2006)
National Asthma Council
Asthma Victoria
Asthma Courses
Respiratory updates and training programs
Other Division service offered is guidelines on Quality Assurance and Callibration of spirometers. The Association has a 3 litre syringe which may be loaned out to practices for use on their spirometers. See link for spirometer information. Contact Rowena Mulligan for further information on 8792 1900.
Refer Resources SectionCDM - Enhanced Primary Care
The Association offers support and information relating to the MBS items for conducting health assessments, care planning and case conferencing. Practice visits are offered to provide up-to-date information and useful tips. Care planning and health assessment forms and screening assessment tools can be found at Resources - Care Plan and Health Assessment Tools.
Diabetes
The growing epidemic of diabetes and associated conditions creates significant challenges within general practice. The Association is committed to working with general practice to better link persons at risk of developing diabetes and those diagnosed with Type 2 diabetes to appropriate local services.
(It is recommended that persons with Type 1 diabetes are best managed by an Endocrinologist and specialist team of diabetes health care professionals.)
The Association also provides educational opportunities for GPs and Practice staff to keep abreast of the latest advances in diabetes and related conditions through CPDs, practice visits, newsletter articles and opportunistically.
The Diabetes Co-ordination and Assessment Service (DCAS) is the Association's centre for all diabetes enquiries. DCAS is staffed by an experienced team of health care professionals and can be contacted by phone on 8792-1922 or fax 9793-9052.
Type 2 Diabetes Services
The Association supports general practice teams to provide care to people with type 2 diabetes, ensuring timely referrals to community and hospital based services.
Services include:
- Diabetes health care assessment
- Self-management education
- Specialist management advice
About the Service
- Self-management education courses
Group education is available for clients at any stage of diabetes, including those:
- At risk of developing diabetes and /or (pre-diabetes)
- With newly diagnosed type 2 diabetes
- With pre-existing type 2 diabetes with or without complications.
Group programs teach participants about diabetes and self-care. Topics covered may include healthy eating, physical activity, foot care, and blood glucose monitoring. The groups are conducted by health professionals at local community health services in a series of sessions (for example 4 weekly group sessions).
Individual sessions are available for patients who require an interpreter or whose needs cannot be met in group education.
A small fee applies for group sessions and a means tested fee applies to individual appointments. - Specialist advice
The Diabetes Cardiovascular Advisory Clinic (DCAC) is designed to support general practice teams with the management of patients with type 2 diabetes who are at risk of or have cardiovascular disease. (The general practitioner continues to be the primary care coordinator)
The Diabetes Cardiovascular Advisory Clinic is based at the Dandenong Hospital and is staffed by a team including an Endocrinologist, Dietitian and a Diabetes Clinical Nurse Consultant. This multidisciplinary team will assess and provide the individual and their GP with treatment recommendations to meet the desired clinical outcomes.
The multidisciplinary clinic team also has the capacity to facilitate insulin initiation and stabilization where indicated.
How to Refer
DCAS accepts referrals for
- Patients with type 2 diabetes
- Patients at risk of developing diabetes, including those with pre-diabetes
We are now accepting referrals via the Argus secure electronic communication software at dddgp_arguspgref@dddgp.com.au . Of course you can always fax DCAS (9793-9052 or 9793-4050) a completed Victorian Statewide Referral Form (VSRF) with clinical information click here (an electronic template can be loaded onto your medical software by contacting DCAS).
After receiving a completed referral, DCAS will assess and triage the referral. One of our health professionals will telephone the patient and coordinate the appropriate services after which the referring GP will be faxed a Referral Feedback Sheet that details the services your patient has agreed to attend.
To download a summary of services or more information on Diabetes Management in General Practice, click on the Resources tab.
^ back to topRefer Resources SectionMental Health
Mental Health has become a key issue within the community. The Association is involved in a range of activities aimed at improving GP understanding and management of mental health issues.
Mental Health Medicare Items (Assessment, Plan, Review)
The Association can provide advice on completing the requirements for these items, and has service agreements with a number of service providers through the Access to Allied Psychology Services program. Details of these providers are available on request. (electronic templates available through Monash Division website)
Access to Allied Psychology Services
This program has been operating since 2002 and in 2007 gained ongoing funding status by the Department of Health and Ageing. Registration with the Association enables GPs to utilise a voucher-based referral system that means patients can attend participating psychology services that are funded through Division brokerage (available to all member GPs). This program also supports a 0.4 EFT visiting psychology service at the Bunurong Aboriginal Health Service.
Links with Mental Health Services
The Association has direct links with a number of services within the Southern Health Area Mental Health Service (particularly the Primary Mental Health Team and the Mental Health GP Liaison Officer). We are also involved in various activities with other community based services, such as ERMHA (psychiatric disability rehabilitation service).
Southern Health Psychiatric Triage Service: 1300 369 012
(see also: Southern Health Mental Health Services)
^ back to topRefer Resources Section