Indigenous Chronic Disease Package
Step 3. Develop a care plan for patients with a chronic disease
Table of contents
- Improve your Aboriginal and Torres Strait Islander patients’ health
- GP and Patient Journey flowchart
How to participate in this program- Step 1. Register the practice/service with Medicare as a participant in the Practice Incentives Program Indigenous Health Incentive
- Step 2. Offer health checks to the Aboriginal and Torres Strait Islander patients in your care
- Step 3. Develop a care plan for patients with a chronic disease
- Step 4. Provide ongoing monitoring of ‘at risk of chronic disease’ patients
- Step 5. Re-register patients annually for the PIP Indigenous Health Incentive
- Registering your practice/service for the PIP Indigenous Health Incentive
- Registering your eligible patients for the PBS Co-payment measure
- Cultural awareness training: who needs it?
- Defining ‘chronic disease’ and ‘at risk’
Identifying and signing up eligible patients- Specialist Outreach Programs and Care Coordination
- Indigenous Health Project Officers: A resource for General Practices and Indigenous Health Services
- Aboriginal and Torres Strait Islander Outreach Workers
- Chronic disease self-management accredited training for staff
- National Tackling Smoking Workforce
- Healthy Lifestyle Workers
- MBS Item numbers for Aboriginal and Torres Strait Islander health services
- General restrictions
Develop a GP Management Plan (MBS Item 721) for patients with a chronic or terminal medical condition. For patients with a chronic medical condition and complex care needs, develop Team Care Arrangements (MBS Item 723). In addition to the item requirements, care planning may include:
- Determining patient eligibility and obtaining patient consent to register for the PIP Indigenous Health Incentive;
- Assessing patient need for PBS Co-payment measure support and seeking their consent to be registered for the PBS Co-payment measure;
- Arranging specialist and allied care services as appropriate;
- Assessing patient need for additional support through Care Coordination and Supplementary Services Program (CCSS)*;
- Accessing additional support for patients to attend medical appointments through local Aboriginal and Torres Strait Islander Outreach Workers*; and
- Referring to additional support services such as regional tobacco action workers and Quitline, for culturally appropriate quit smoking programs; and healthy lifestyle workers for culturally appropriate nutrition and exercise programs*.
Benefits to your practice/service:
(i) Patient Registration Payment: receive $250 per year for each eligible patient registered with the general practice or Indigenous Health Service for chronic disease management through the PIP Indigenous Health Incentive.(ii) Outcomes payment: annual payments to the general practice or Indigenous Health Service of up to $250 for each eligible patient for whom a target level of care has been provided and the practice/service has provided the majority of care for the registered patient.
(iii) Prescribe more affordable PBS medicines for your eligible Aboriginal and Torres Strait Islander patients through the PBS Co-payment measure.
(iv) Provide up to 10 practice nurse or Aboriginal Health Worker follow-up services and up to 10 services from selected allied health providers, for each Aboriginal and/or Torres Strait Islander patient following a health assessment (per calendar year).
(v) Access specialist and allied health services for your patient through the Care Coordination and Supplementary Services Program*, Urban Specialist Outreach Assistance Program* and the Medical Specialist Outreach Assistance Program – Indigenous Chronic Disease.
(vi) Access additional support services such as regional tobacco action workers, healthy lifestyle workers and Aboriginal and Torres Strait Islander Outreach Workers.
* These programs are being implemented progressively over the period 2009-10 to 2012-13. Your Division of General Practice or NACCHO Affiliate will let you know when they become available in your area.