1. Why do a care plan?
2. Requirements for a care plan?
3. How to initiate a care plan
4. Preparation
5. The Care Plan
6. Documentation
7. Programs
8. Contributing to a care plan
   

A care plan can be initiated by either a GP or another health care provider who links the plan to a GP

If you are a GP, why do a care plan?

• It enables you to match patient needs to services
• It offers longitudinal care with regular reviews
• Multidisciplinary care is being provided for the patient with GP contribution
• Other care providers are formally linked
• The care plan is a reference point for other health care providers
• Care plans may be able to be used in hospital discharge
• The patient agrees to the plan, and in doing so, shows commitment to care
• Regular reviews provide for ongoing care
• A care plan is able to support a GPs contribution to the health priority areas of cardiovascular disease, cancer, asthma, injury and diabetes
• The Plan is not restricted by a patient's age
• As a GP you are paid for this by using MBS Item Numbers 722,720,724,728 or 726

What are the requirements for a care plan?

• Refer to Medicare Benefits Schedule Book 1 Nov 1999 and supplement 1 May 2000. Additional information is available in the RACGP guidelines.
• The patient must have a chronic condition (one which lasts for 6 months or more), require multi-disciplinary care or have a terminal illness;
• A care plan is NOT dependent on the age of the patient;
• The care plan must include at least 2 other health professionals who provide different services;
• The plan, which meets multi-disciplinary needs, must be written and used to describe:
  
  
  • Assessment of health care needs
  • Assessment of services and treatment required
  • Arrangement for services and treatment
  • Management goals with which the patient agrees
  • A date by which the plan will be reviewed

• A GP may initiate the care plan or another provider may initiate it and the GP contribute;
• The other health providers may be, for example:

Medical specialist	Social worker	Dietitian
Dentist	Optometrist	Occupational Community nurses
Home help	organisation	therapist
Aboriginal health worker	Audiologist	Physiotherapist
Community support groups	Continence Adviser	Podiatrist
Education provider	Respite care	Psychologist
Pharmacist	Meals on Wheels	Speech
Specific patient programs	Parole officer	pathologist
Patient support groups	Counsellor	Gymnasium
	Massage therapist

How to initiate a care plan

The statutory requirements are found in the Medicare Benefits Schedule

Additional information is available in the 'Enhanced Primary Care Kit' sent to you by the Commonwealth Department of Health and Aged Care.

'At a Glance' contained in the Kit, summarises the care plan process.

• A care plan team must include a GP and at least 2 other contributing members who provide a different service
• The patient must have a medical condition that has been or is likely to be present for at lease 6 months or that is terminal

Preparation

• Check for an existing care plan
• Discuss with the patient who will be in the team
• Disclose to the patient any fees that will be incurred
• Obtain patient's consent
• Inform the patient of the need to share information with the other providers and ask the patient if there is any information they do not want shared

The Care Plan

• The patient must be assessed using a biopsychosocial assessment (refer to health assessment)
• Identify patient needs
• List problems and diagnosis
• Identify treatment, health services, health care and community services the patient may need
• These services must be available, able and willing to participate
• Identify and list management goals which the patient understands and agrees with
• Specify a date for a review of the plan

Documentation

• A written care plan must be kept with the patient's record
• The patient signs the care plan and receives a copy or a summary
• The other health providers receive a copy of the care plan which identifies their contribution and the patient's goals
• Schedule a date for review progress of goals and objectives
• As a GP you may claim Medicare Item Numbers:
  
  
  • 722 for a hospital discharge care plan (check rules for patient and hospital status)
  • 720 for a non-hospital care plan
  • 724 for a review of a care plan (3 months after initiation)

Programs

As a GP you may be able to claim an EPC MBS item number by referring your patient to other formal care providers within a program setting. For example, such a program may be about caring for:

• Diabetes
• Cardiovascular disease
• Palliative care
• Mental health
• Medications in the community
• Injury prevention and control
• Falls prevention
• Smoking cessation
• AIDS

If you are a GP and contributing to a care plan

• Ensure the patient has consented to the care plan
• Make sure the patient is aware of any costs involved
• Communicate with the care plan initiator for at least 10 minutes
• A contribution would include the treatment being provided by the GP
• The GP should inform the patient that their medical history, diagnosis and care preferences will be discussed with the other providers and the patient may want to specify that some information be withheld
• The GP needs to obtain a copy of the care plan and keep it with the patient's record
• As a GP you may claim Medicare Item Numbers
  
  
  • 728 for contributing to a hospital discharge plan
  • 726 for contributing to a non hospital care plan