Chronic Disease Management
Chronic diseases are long-lasting conditions with persistent effects. So it's not just about illnesses that resolve after a single episode, but those that persist and can be more complex to manage than the average illness.
Heart disease, kidney disease, emphysema-these common ailments will often stay with you for your whole life if they’re left untreated or poorly managed by doctors who don’t know what matters in managing them! On the other hand, with good management of chronic diseases, there is no need for complicated treatments because it’ll all work itself out over time. As long as you do this well enough, then everything should come up roses (in other words, things could go worse!).
FAQ's About Chronic Disease Management
The Chronic Disease Management (formerly Enhanced Primary Care or EPC)-GP services on the Medicare Benefits Schedule (MBS) enable GPs to plan and coordinate the health care of patients with chronic or terminal medical conditions, including patients with these conditions who require multidisciplinary, team-based care from a GP and at least two other healthcare providers.
To be eligible for any CDM services, a patient must have a chronic or terminal medical condition. This one has been or is likely to be present for six months or longer and includes, but is not limited to, asthma, cancer, cardiovascular illness, diabetes mellitus, musculoskeletal conditions, and stroke.
The Medicare Benefits Schedule (MBS) does not list all possible medical conditions that are or are not regarded as chronic medical conditions for the CDM.
Whether a patient is eligible for a CDM service or service is essentially a matter for the GP to determine, using their clinical judgment and considering the eligibility criteria and the general guidance. Where a patient’s’ condition ’would not come within the MBS definition, a GP may still consider the patient’s condition and circumstances. They require the preparation of a care plan because of such factors as non-compliance, inability to self-manage or functional disability.
A GP Management Plan can help you if you have a chronic or terminal medical condition by providing clear guidelines for your care. The plan is an agreement made with your GP, identifying healthcare needs, setting out their services, and others, such as physical therapy or pain management clinics.
This plan covers the following aspects.
- The patient’s health care needs, health problems, and relevant conditions;
- Management goals with which the patient agrees;
- Actions to be taken by the patient;
- Treatment and services the patient is likely to need;
- Arrangements for providing this treatment and these services; and
- Arrangements to review the plan by a date specified in the plan.
Team Care Arrangements (TCA) Plan
Patients with chronic or terminal medical conditions and complex needs, such as ongoing care from a multidisciplinary team, may find themselves with Team Care Arrangements Plans put in place by their doctor. This allows your doctor to work together with at least two other health professionals to provide treatment services.
This plan covers the following aspects.
- Treatment and service goals for the patient; and
- Treatment and services that collaborating health professionals will provide to the patient; and
- Actions to be taken by the patient; and
- Arrangements to be reviewed by a specified date; and
- Explain the steps involved in the development of the structures to the patient and the patient’s carer
- Collaborating health professionals will discuss with patients who will contribute to developing the TCAs and providing treatment and services under those arrangements.
- Record the patient’s agreement to the development of TCAs; and
- Give copies of the relevant parts of the document to the collaborating health professional; and
- Offer a copy of the document to the patient and the patient’s carer (if any, and if the practitioner considers it appropriate and the patient agrees); and
- Add a copy of the document to the patient’s medical records.
Chronic Disease Management Plans offer several benefits. It can:
- can improve exercise tolerance.
- Boost your activity levels and function
- Providing you with the skills and education you need to take care of your health.
- This will improve the quality of your life.