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• Indigenous Chronic
  Disease Package
• Tackling Chronic Disease
  Risk Factors
  • National action to reduce Indigenous smoking rate
  • Helping Indigenous Australians to reduce their risk of chronic disease
  • Local Indigenous community campaigns to promote better health
• Improving Chronic Disease
  Management and Follow up
  • Subsidising PBS medicine co-payments
  • Higher utilisation costs for MBS and PBS
  • Supporting primary care providers to coordinate chronic disease management
  • Improving Indigenous participation in health care through chronic disease self management
  • Increasing specialist and allied health follow up care
  • Monitoring and evaluation
• Workforce Expansion,
  Training and Support
  • Workforce education and training
  • Expanding the outreach and service capacity of Indigenous health services
  • Engaging Medicare Locals to improve Indigenous Access to mainstream primary care
  • Attracting more people to work in Indigenous Health
  • Clinical practice and decision support

1. Information for General Practitioners on the Indigenous Chronic Disease Package

• General Overview

1. Information for General Practitioners on the Indigenous Chronic Disease Package
2. Patient identification
3. Practice Incentives Program (PIP) Indigenous Health Incentive
4. Aboriginal and Torres Strait Islander health assessment items
5. MBS items overview
6. Chronic disease follow-up services
7. Allied health follow-up services
8. Practice nurses/Registered Aboriginal Health Worker follow-up services
9. Pharmaceuticals Benefit Scheme (PBS) Co-payment measure
10. Care Coordination and Supplementary Services Program (CCSS)

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The Australian Government’s Indigenous Chronic Disease Package aims to close the life expectancy gap between Indigenous and non-Indigenous Australians. The package focuses on:

• Promoting good health by reducing the risk factors for chronic disease;
• Improving access to primary health care and follow-up services; and
• Expanding the Indigenous health workforce.

The Package offers a range of initiatives and incentives to support you and your team in providing quality primary health care to Aboriginal and/or Torres Strait Islander people with chronic disease; and at risk of developing chronic disease.

Chronic Disease

Chronic diseases causing the highest rates of mortality for Aboriginal and Torres Strait Islander people include:

• cardiovascular disease;
• diabetes;
• chronic respiratory disease;
• cancer; and
• chronic kidney disease.

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Initiatives to help you care for those with chronic disease

Aboriginal and Torres Strait Islander Health Assessment (MBS item 715)

Offering a comprehensive health assessment (MBS item 715) provides an opportunity to check for risk factors and chronic disease and to begin the process of developing a care plan if needed. More information: Detail Card 4

The Practice Incentives Program Indigenous Health Incentive (PIP)

Registering your Aboriginal and/or Torres Strait Islander patients who have a chronic disease will help you to provide them with best-practice chronic disease management and active follow-up, and will provide your practice/service with a range of incentive payments through the Australian Government’s PIP Indigenous Health Incentive. More information: Detail Card 3 and www.medicareaustralia.gov.au/pip

The PBS Co-payment measure

You can prescribe more affordable, and in some instances free, PBS medicines for your registered Aboriginal and/or Torres Strait Islander patients who meet the measure’s eligibility criteria. More information: Detail Card 9 and http://www. health.gov.au/internet/ctg/publishing.nsf/Content/subsidisingpbs- medicine-co-payments

Care Coordination and Supplementary Services Program

You can access assistance in care coordination for your Aboriginal and/or Torres Strait Islander patients with complex care needs. location: Regions of high need. More information: Detail Card 10 and http://www.health.gov.au/internet/ctg/publishing.nsf/ Content/improving-frontline-health

Medical Specialist Outreach Assistance Program (MSOAP) - Indigenous Chronic Disease (MSOAP-ICD) measure

In rural and remote areas, MSOAP has been expanded to include multidisciplinary teams of specialists, GPs and/or allied health professionals for Aboriginal and Torres Strait Islander chronic disease care. location: In Australian Standard Geographical Classification (ASGC) – Remoteness Areas (RA) 2 (Inner Regional) to 5 (Very Remote) identified through a needs assessment and prioritisation process.More information:http://www.health.gov.au/internet/ctg/publishing.nsf/Content/ access-multidisciplinary

Urban Specialist Outreach Assistance Program (USOAP)

In urban areas, Aboriginal and/or Torres Strait Islander patients with a chronic disease can access outreach medical specialist services. location: The program has begun in NSW,QLD, VIC and WA. timing: Started May 2010. More information: http://www.health.gov.au/internet/ctg/publishing. nsf/Content/access-multidisciplinary

Regional initiatives

You will be supported by new workforce positions such as Indigenous Health Project Officers located in most Divisions of General Practice (DoGP) and the National Aboriginal Community Controlled Health Organisation Affiliates. More information: Your local DoGP or National Aboriginal Community Controlled Health Organisation (NACCHO) Affiliates.

Benefits for Aboriginal and Torres Strait

Islander Patients

Earlier detection of chronic disease and risk factors All Aboriginal and Torres Strait Islander patients are eligible to receive annual Aboriginal and Torres Strait Islander Health Assessments. These help to screen for risk factors and identify chronic diseases that could be managed through medical treatment.

Practical support

Local Aboriginal and Torres Strait Islander Outreach Workers may be available to organise transport or help organise attendance for patients at follow-up appointments and appointments with other health providers.
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The Care Coordination and Supplementary Services Program provides a flexible funding pool to enable Aboriginal and Torres Strait Islander patients with chronic disease to access specialist and allied health services, as outlined in their care plan.

Ability to access risk modification and programs

A new Tackling Smoking and Healthy Lifestyle workforce will be available to help individuals and communities make healthy choices about nutrition, exercise and to quit smoking. Such interventions can help prevent or delay the development of chronic disease. More information: http://www.health.gov.au/internet/ctg/ publishing.nsf/Content/expanding-outreach

Improved access to affordable medicines

Accredited practices and practices working towards accreditation, including Indigenous health services can prescribe more affordable PBS medicines for eligible Aboriginal and Torres Strait Islander patients with, or at risk of, chronic disease, and who meet the measure’s needs-based criteria.

Benefits for general practices and Indigenous Health Services

Additional resources

Accredited Indigenous Health Services and general practices and those working towards accreditation are eligible to access significant additional resources through the new PIP Indigenous Health Incentive.

Ability to prescribe PBS medicines that patients can afford to fill

Increased access to PBS medicines will help improve the prevention and management of chronic disease for Aboriginal and Torres Strait Islander people. The PBS Co-payment measure is available for patients with, or at risk of, chronic disease who also meetneeds-based criteria (see Detail Card 9 for further information).

Additional workforce

Additional workforce are being funded, including:

• more than 160 new Aboriginal and Torres Strait Islander Outreach Workers employed in Divisions of General Practice and Indigenous Health Services, to work with their community to increase engagement with health services and provide practical support for Aboriginal and Torres Strait islander people to attend appointments and follow-up care; and
• the rollout of a new Tackling Smoking and Healthy Lifestyle Workforce taking a regional, team-based approach to reducing lifestyle risk factors and promoting quit smoking messages in a culturally appropriate manner.

Increased training and education

Additional training posts for GP registrars in Indigenous Health Services and the expansion of current nursing scholarship program arrangements.

General Practitioner checklist

• Prepare practice as needed for Indigenous chronic disease management (develop recall system, update records)
• Undertake cultural awareness training for at least two staff as required for the for PIP-IHI
• Register practice/Indigenous health organisation with Medicare Australia for the PIP-IHI
• Establish process for asking patients about Indigenous status
• Include patient’s family
• Assess for chronic disease and risk factors through Aboriginal Health Assessment (MBS Item 715)
• Seek patient consent and register patient for PIP-IHI and/or PBS Co-payment measure
• Develop a care plan
• Ring and refer to specialists and allied health providers
• Refer to care coordination and supplementary services if appropriate
• Annotate PBS prescriptions for registered patients for cheaper medicines
• Recall patient and review care plan on a regular basis
• Re-register patient annually (for PIP-IHI only)

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Page currency, Latest update: 09 December, 2010

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