1. Care Planning for
Improved Health Outcomes
Karen Booth RN

2. Care Planning GPMP/TCA
Improve Outcomes by Mapping Care
• Co-ordinate complex health care needs
• Pt may see more than one health professional, without the doctor
knowing
• May need a new or more appropriate referral
• Clear goals & management strategies
• Pt & GP team agree on goals uses Mx plan as care contract
• Remuneration
• Comprehensive, written management plan / record for the GP, practice nurse
and other professionals1

3. Benefits of Care Planning
• evidence-based management of health and care needs
• Allows for coordination of complex health care needs
• Reduces the need for ad hoc consultations
• Encourages proactive preventive care
• Promotes teamwork
• Improves patient outcomes (BEACH Study)

4. When is a TCA appropriate?
When a patient has:
• a need to see other providers on a regular, frequent and ongoing basis
• reduced capacity to access services by the usual processes
• an unstable or deteriorating condition and/or co morbidities
• increasing frailty /dependence/complexity
• significant change in social circumstances
•  two hospital admissions for their condition in the past six months
• inability to comply with required treatment without ongoing management and
coordination
1. Department of Health & Ageing. Chronic Disease Management (CDM) Medicare Items. Q & As. Available at:
www.health.gov.au/internet/wcms/publishing.nsf/Content/pcd-programs-epc-chronicdisease

5. What can practice nurses do?
• Gather and document relevant patient information1
• Assist with clinical assessment (as agreed with GP)
• Identify & document patient needs
• Care plan preparation
• Advance role of PN in care co-ordination as part of GP team
(e.g. CVC Model)
• Provide lifestyle education & self-management advice
• Communicate and liaise with service providers
• Recall and reminder systems for patient reviews
1. Department of Health & Ageing. Chronic Disease Management (CDM) Medicare Items. Q & As. Available at:

6. Nurse Item 10997 for CDM
• 5 visits to PN per year for pts with GPMP
+/- TCA
• Ongoing monitoring & or health advice as part
of care plan
• Data collection for care plans, diabetes cycle,
asthma
• $11.35 (March 2010)

7. Short Cuts
Set up templates in software to:
• Auto fill pt info: Details, Dx Measurements,
providers
• Use only relevant Dx in plan,
• Can put other Hx in summary
• Set up spread sheet of most common problems,
goals & actions

8. Remember
• Care plans take time (Can’t pluck a care plan from thin air)
• Needs a whole of team approach incl., booking,
nurse appt, dr appt
• Book pt with nurse for 30 mins to allow time for
documentation & corrections, adding info
• Nurses are a valuable resource – your investment in
their education will bring reward to the practice

9. Care Plan Items
ITEM ITEM MBS
NUMBER
MEDICARE REBATE RECOMMENDED
FREQUENCY
Preparation of a
GP Management Plan
(GPMP)
725 $133.65 2 yearly
*Minimum claiming
period - 12 months
Review of a
GP Management Plan
725 $66.80 6 monthly
*Minimum claiming
period - 3 months
Coordination of
Team Care
Arrangements (TCA)
727 $105.90 2 yearly
*Minimum claiming
period - 12 months
Coordination of a
Review of Team Care
Arrangements
727 $66.80 6 monthly
*Minimum claiming
period - 3 months

10. Allied health professionals-Item numbers

11. GPMP/TCA Templates
• Templates are available on websites including:
– The Department of Health and Ageing (http://www.health.gov.au/) 1
– The Drs Reference Site (http://www.drsref.com.au/epc.html)
(provides links to the different Divisions of General Practice) 2
• Division of General Practice
• Medical software can be used to produce the GPMP and/or TCA (i.e.
medical director)
• Make your own
1.

12. 1. Department of Health & Ageing. Chronic Disease Management (CDM) Medicare Items. Q & As. Available at:
www.health.gov.au/internet/wcms/publishing.nsf/Content/pcd-programs-epc-chronicdisease
2. CDM Items – Checklist. Available at the Department of Health & Ageing website:
www.health.gov.au/internet/wcms/publishing.nsf/Content/pcd-programs-epc-chronicdisease
3. The Northern Rivers General Practice Network. Mitchell C. Introduction to the new GPMPs & TCAs . Available at:
www.nrdgp.org.au/resources.html
4. Zwar N, et al. Aust Fam Phys 2007; 36: 85-89.
Allied Health Services Under Medicare. November 2007. Department of Health and Ageing. Department of Health & Ageing.
Available at: www.health.gov.au/internet/wcms/publishing.nsf/Content/health-medicare-health_pro-gp-pdf-allied-cnt.htm
2. Enhanced Primary Care Program (EPC) Chronic Disease Management (CDM) Medicare Items (new from 1 July 2005).
Department of Health & Ageing. Available at: www.health.gov.au/internet/wcms/publishing.nsf/Content/pcd-programs-
epc-chronicdisease

13. HEALTH NEEDS MANAGEMENT GOALS ACTION REQUIRED PROVIDER REVIEW DATE
Hypertension: BP < 130/80
Reduce risk of cardiovascular event and end
organ damage peripheral vascular disease.
Regular GP review
Regular blood pressure monitoring
ECG & blood test as required.
Annual HT/CV/health assessment.
Patient to report any change in symptoms to GP e.g. headache
Medication.
Regular exercise walking program 30-40 mins most days
Weight reduction Diet low in: fat salt.
Diabetes:
Hypercholesterolemia
HbA1C < 7%.
Stabilise blood sugar
Tch: 4.5
LDL < 2.5
Trig < 2
BP 130/80
Prevent diabetes associated complications:
skin eye circulation sensation kidneys.
Regular GP review
Regular blood test.
Medication as prescribed (triple therapy).
Regular exercise including walking program 30-45 mins 5 days/week & resistance
exercise.
Weight loss. Diet: low fat & salt low GI
Annual diabetes assessment & 6 monthly review
Appropriate foot wear
Team Care:
Referral to podiatrist for assessment & ongoing care 6 monthly neuropathy
assessment & report to GP
Referral to endocrinologist for assessment & optimise therapy as needed
Referral for type 2 Diabetes exercise program
GP
Mr/Ms
Dr
THE LEICHHARDT GENERAL PRACTICE
GP MANAGEMENT PLAN 721 & TEAM CARE PLAN 723
<<Patient Demographics:Full Name>> Prepared by <<Doctor:Name>> <<Miscellaneous:Date>>

14. Risk of diabetes related eye
disease
Preserve vision
Reduce risk of visual diabetes related eye
complications
Tight diabetes control BSL & HbA1c & BP to normal limits.
Pt to report any changes in vision immediately to GP
Medication drops as prescribed
Team Care:
Referral to Ophthalmologist for review optimise therapy & management advice
minimum 2 yearly checks
GP
Dr
Chest Pain
Ischaemic heart disease
Reduce risk of serious cardiac event
Reduce risk of complications associated with
cardiac disease.
Promote independence
Regular GP review
Report any ongoing symptoms to GP
Medication
ECG prn blood test investigation as needed
Diet: Low fat & salt
Regular gentle exercise/ walking / cardiac rehab program
For acute chest pain that does not settle with use of nitrate spray Dial “000”
ambulance
Team Care:
Referal to cardiologist for assessment treatment & management advice
General health Women: Promote health & well-being Annual health check-up & blood test for lipids & BSL
Yearly Flu vaccination due in March
>65 Pneumovax 2 doses (5 years apart)
2 yearly pap smear
>40 2 yearly mammogram
>50 Annual Faecal occult blood test
Next due
General health Men: Promote health & well-being: Annual health check-up & blood test for lipids & BSL
Prostate check
Yearly Flu vaccination
>65 Pneumovax 2 doses (5 years apart)
>65 Pneumovax 2
>50 Annual Faecal occult blood test
Next due