Indigenous Chronic Disease Package
Step 4. Provide ongoing monitoring of ‘at risk of chronic disease’ patients
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
- Assess patient need and eligibility for PBS Co-payment measure.
- Obtain patient consent and complete one-time registration for affordable PBS medicines under the PBS Co-payment measure.
- Access 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 where locally available.
- Access follow-up care from specialist and allied health providers under the Medical Specialist Outreach Assistance Program – Indigenous Chronic Disease (MSOAP-ICD).
Benefits to your practice/service:
(i) Able to prescribe PBS medicines that will be more affordable for your eligible Aboriginal and Torres Strait Islander patients.(ii) Access additional support services for your ‘at risk’ patients such as allied health services and non-clinical support such as regional tobacco action workers and healthy lifestyle workers.
(iii) For rural and remote practices/services, access to specialist and allied health follow-up care. Upskilling may also be available from visiting health professionals under the MSOAP-ICD.