Chronic Disease Management (CDM)
Purpose: The Chronic Disease Management (CDM) items support a structured approach to managing chronic and terminal medical conditions by preparing, coordinating, reviewing, and contributing to care plans. These plans ensure ongoing care from multidisciplinary teams.
Types of CDM Plans
- GP Management Plans (GPMP):
- For patients with chronic medical conditions.
- Involves an organized approach to care by identifying health needs, setting management goals, and planning treatments.
- Team Care Arrangements (TCAs):
- For patients with chronic conditions and complex care needs requiring multidisciplinary care.
- Requires collaboration with at least two other healthcare providers.
Patient Eligibility
- Chronic Medical Conditions: Conditions that have been or are likely to be present for six months or longer, such as asthma, cancer, heart disease, diabetes, arthritis, and stroke.
- Complex Care Needs: Patients requiring treatment from multiple healthcare providers.
- Mental Health Conditions: Patients being treated under the Better Access initiative or with an Eating Disorder Treatment and Management Plan (EDTMP).
CDM Items and Claiming Periods
| Description | Item No | Minimum Claiming Period |
|---|---|---|
| Preparation of a GP Management Plan (GPMP) | 721 | 12 months |
| Coordination of Team Care Arrangements (TCAs) | 723 | 12 months |
| Contribution to a Multidisciplinary Care Plan for a non-residential aged care facility patient | 729 | 3 months |
| Contribution to a Multidisciplinary Care Plan for a residential aged care facility resident | 731 | 3 months |
| Review of a GPMP or TCAs | 732 | 3 months |
Exceptional Circumstances
- Services can be provided more frequently if there is a significant change in the patient’s clinical condition or care requirements.
Documentation Requirements
GPMP Documentation:
- Preparation:
- Explain the plan preparation steps to the patient.
- Record the patient’s agreement.
- Describe the patient’s healthcare needs, management goals, treatment/services needed, and review arrangements.
- Offer a copy to the patient and add to their medical record.
- Retain the plan for 2 years.
- Content:
- Patient’s health care needs, health problems, and relevant conditions.
- Management goals and actions for the patient.
- Treatments and services required.
- Arrangements for providing treatments/services.
- Review arrangements and dates.
TCAs Documentation:
- Preparation:
- Consult with at least two other healthcare providers who provide different types of treatment or services.
- Record the patient’s agreement to the TCAs.
- Discuss the multidisciplinary team contributing to the TCAs.
- Offer a copy to the patient and collaborating providers, and add to the patient’s medical record.
- Retain the document for 2 years.
- Content:
- Treatment and service goals.
- Treatments and services provided by collaborating providers.
- Actions the patient needs to take.
- Review dates.
Patient Review and Coordination
- Reviewing GPMPs and TCAs:
- Regular reviews ensure goals are met and necessary adjustments are made.
- Use Item 732 for reviews, claimable every 3 months or more frequently in exceptional circumstances.
- Involves patient consultation, updating the plan, and sharing updates with the healthcare team.
Eligibility:
- CDM Items 721, 723, and 732: Available to community patients and private in-patients being discharged from the hospital, including those in aged care facilities. Not available to public in-patients or residential aged care facility residents.
- CDM Item 729: Available to community patients and both private and public in-patients being discharged from the hospital. Not available to residential aged care facility residents.
- CDM Item 731: Available only to care recipients in residential aged care facilities.
- Claiming Restrictions:
- Cannot co-claim CDM items with certain general consultation items on the same day.
- Review items can be claimed up to three times on the same day for different reviews (e.g., GPMP, TCAs for CDM, TCAs for MH/ED).
Allied Health Services
- Eligibility: Patients with both GPMP and TCAs may be eligible for Medicare rebates for specific allied health services.
- Service Limit: Up to 5 individual services per year.
- Group Services: Additional services available for patients with type 2 diabetes (e.g., diabetes education, exercise physiology, dietetics).
- Documentation: Allied health professionals must report back after the first and last individual service, with additional reports as needed