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Supporting nurses
in primary health care
www.apna.asn.au
1300 303 184
[email protected]
Person
Centred
Care
Planning
Ros Rolleston RN
Primary Health Care Nurse & Educator
[email protected]
December 2014
Learning Objectives

Discuss practice funding

Describe Medicare eligibility & requirements

Develop person centred approach to chronic
disease management

Improve multidisciplinary team communication
Practice Funding

Practice Nurse PIP
$25000:1000 SWPE for RN working 12.6hrs/wk
 Rural and AMS loading


Diabetes PIP

Asthma PIP
CDM Rebates

GPMP/TCA – 721/723
 $258.55

Review GPMP/TCA – 732x2
 $144.10

Contribution to RACF care plan – 731
 $70.40

Contribution to another’s care plan – 729
 $70.40

Monitoring & support by GPN – 10997
 $12
http://www9.health.gov.au/mbs/search.cfm?q=721&sopt=S
GP Time Based MBS Rebates

Asthma Cycle of Care, 2546/52/58
 $37.05 – $105.55

Diabetes Cycle of Care, 2517/21/25
 $37.05 – $105.55

Mental Health Care Plan, 2700 series
 $71.70 – $134.10

GP consultation item numbers no longer
claimable on the same day as CDM services
http://www9.health.gov.au/mbs/search.cfm?q=2700&sopt=S
MBS Eligibility

Chronic illness 6m

Clinical decision of the GP

Mental health

Reduced capacity to self care

Intellectual or physical disabilities including kids

Obesity, BP, lipids, glucose, LFTs

RACF, hospital discharge
http://www9.health.gov.au/mbs/fullDisplay.cfm?type=note&q=A37&qt=noteID&criteria=721
MBS Requirements

Document consent

Written plan

Person agreed goals

2 ongoing providers

Collaboration with other providers
http://www9.health.gov.au/mbs/fullDisplay.cfm?type=note&q=A37&qt=noteID&criteria=721
Review & Renew Periods

3-6 months review

12-24 months care plan

Clinical guidelines

Exceptional circumstances
MBS Online
http://www9.health.gov.au/mbs/fullDisplay.cfm?type=note&q=A37&qt=noteID&criteria=721
Person Centred
Assessment
Team Based Care

Collaborative team meeting

Agree on GPN & GP roles

Patient identification

Appointment scheduling

Template selection

Database research

Organisation of recalls
Together
we can
achieve
Auto Fills & Short Cuts – GP

I have discussed the care planning process with my
patient who has given their consent to have a
GPMP/TCA developed with the GPN

I have updated the past history and medications

Illnesses to be included:

Other Providers to be included:

Review period: 3 months
Auto Fills & Short Cuts – GPN

Referred by… for preparation of an initial care plan for…

Discussed the process and billing

Discussed referrals and potential costs

Review period of 3 months due to…

Consent given to proceed

Today’s assessment –
Setting the Scene

1 hour appointment

Arrange for no interruptions

Active listening

Body language

Open ended questions

Include person in decisions
Review History

Look at the billing

Set reason for visit

Update reminders and recalls

Load template

Autofills

Go through the whole file
In the Beginning...

BMI

BP, P & regularity, SpO2, BGL

Informed consent

Medications

Pathology

Family history

Smoking, alcohol
Needs Assessment

Rate your health 1-10

Main health concern

Duration of illnesses

Knowledge of illnesses
Nutrition

Is your diet healthy

Breakfast, lunch, dinner

Fruit & vegetables

Meats, dairy & bread

Water & salt

Processed foods, takeaways, snacks
Activity

How active is your lifestyle

Activities you enjoy

Barriers to activity

Specific exercise

Are you stable on your feet
Mental Health & Wellbeing

Daily routine

Do you ever feel sad or alone

Do you have any worries

Sleep patterns

Substance use

Self harm, suicidality
Medications

Concurrence

Side effects

Complimentary therapies

Regular Pharmacist

HMR
Vaccination

Influenza

Pneumococcal

Hep B

dTpa

MMR

Zoster
http://www.health.gov.au/internet/immunise/publishing.nsf/content/Handbook10-home
Medical Guidelines
CVD, Diabetes & CRF

22% CVD

10% CRF

68% with diabetes have CVD or CRF

 Mortality rate in Indigenous & socioeconomic
disadvantaged groups
Cardiovascular Risk Assessment

TC, LDL, TC:HDL ratio

Triglycerides

LFTs

BP, P, BGL

Statin, antiplatelet

ED

ECG
Renal Protection

eGFR

Microalbuminuria

ACR

BP, BGL

U/E/C, K+

ACE or ARB

NSAID
Microvascular Circulation

Vision

Feet

Lungs

Cognition
Further Investigation

FBE

CRP

Na+

B12

Vitamin D
Goal
Setting
Personal Goals

Person centred

Maximum of 3

Stages of change

Health coaching

SMART Goals
 SMall
 Authentic
 Re-evaluate
 Timeframe
Advanced Care Directives

Document persons wishes for care & treatment
before they are unable to speak for themselves

Discussion with family & GP discussion

Enduring guardian has the responsibility for
health care

Enduring power of attorney has the
responsibility for financial and real estate affairs
http://www.advancecaredirectives.org.au/
Collaboration
Referrals & TCA

Dietitian, Exercise Physiologist, Podiatrist

Physiotherapist, Osteopath, Chiropractor

Optometrist, OT, Speech Pathologist

Pharmacist, HMR

Dentition

CNC, ACAT

Specialists

List all team care members on care plan
Handover

Cruical for successful CDM

Person relays the messages

Post-it note

Phone call

Intranet message

Email

Face to face
CDM Folder

Engages person

Personal role

Personal responsibility

Team communication

Houses a contemporaneous
and complete health history
My
Health
Plan
Acknowledge Person

Thank the person for coming

Congratulate them on becoming an active
participant in their health care

Invite the them to call if they have any questions
Nurse Case Managers

Ongoing contact

Coordinating care

Disease surveillance

Independent of GP

GPN can be TCA member
Person Centred Medical Home
Forward Planning

23, 10997, 10987, 732, 2517, 2546, 2713, 2715

Regular appointments

BP, INR, BGL monitoring

Health coaching, goal attainment, education

Weight & activity monitoring

Vaccination

ECG, Spirometry, Dopplers
Business Model
Consultations
Item Number
GP Time
GPN Time
GPMP
721
10
45
144.25
TCA
723
15
114.30
Reviews
732
30
45
432.30
GP Consults
23
80
GPN Monitoring
10997
ECG
11700
31.25
Bulk Billing
10991
238.70
TOTAL year
296.40
75
120
Billing
180
60.00
$ 1317.20
TOTAL month
$109.77
TOTAL hour
$263.44
Web Resources

Better Health Channel

CVC Program

Flinders University

Health Change Australia

MBS Online

RACGP
Thank You