Chronic Disease Management
Chronic Disease Management (CDM) in General Practice involves appropriate prevention, early identification and best practice management strategies.
This page contains resources for all members of the General Practice Team involved in Chronic Disease Management.
Ballarat Community Health Centre
New! Ballarat has four Community Health Centres (BCHC) with a number of different programs available.
The following sites may be of interest when developing chronic disease management plans:
- See an overview of services available through BCHC, follow the links to individual programs
- Categorised information on programs and events, just scroll down to see what's available
- BCHC also has a self management program (called HiP) available to patients with chronic diseases
Cancer Services
The Grampians Cancer Support Service Directory has been developed by GICS to assist with supporting cancer patient's needs throughout their cancer experience.
New! Women's Health Grampians have developed a comprehensive list of breast cancer support services in the Grampians Region.
Cancer Care Case Conference - MBS Items 871 & 872
On November 1st 2006 DoHA released two new Cancer Care Case Conference items to support an integrated team approach for prospective treatment and care planning for patients with cancer. They are:
- Item 871 - GP lead multi-disciplinary Case Conference, and
- Item 872 - GP participates as a member of a multi-disciplinary Case Conference team.
These items will support an integrated team approach for prospective treatment and care planning for patients.
Information about the new items is available in this flowchart and this Cancer Care Case Conference MBS items descriptor sheet.
For more information: DoHA MBS Online summary of changes or Medicare Benefits Schedule Book November 1, 2006 page 81 & 115.
45+ Health Check (MBS Item 717)
Introducted 1st Nov 2006 for patients between the ages of 45 and 49 (inclusive) who are at risk of developing a chronic disease.
Sample practice letter for patients that do not attend their General Practice regularly.
RACGP resources, including:
- Checklist
- Templates letters to patients
- The Red Book: RACGP guidelines for preventive activities in general practice (6th Edition 2005)
- The Green Book: RACGP Putting Prevention Into Practice
- RACGP SNAP: A Population Health Guide to Behavioural Risk Factors in General Practice. (SNAP = quit Smoking, better Nutrition, moderate Alcohol, Physical activity)
RACGP - Organisational issues for consideration, including:
- Identifying eligible patients
- Patients readiness to change
- Referrals
DoHA resources, including:
- Fact sheet
- Questions and answers
- Checklist
NEVDGP resources, including:
- New! Practice Wall Chart for the 45-49 Year old Health Check (PDF)
- Template for 45+ health check
To support effective use of the Medical Director template on the NEVDGP website and the item number the ADGP has created a wall chart of 'how to' tips (PDF).
Mental Health Care Plan
The new Mental Health Care items (introduced 1 Nov 06) provide a structured framework for GPs to undertake early intervention, assessment and management of patients with mental disorders, as well as providing new referral pathways to clinical psychologist and allied mental health service providers, including:
- MBS item descriptors
- MBS explanatory notes
- Question and Answer booklet
- Mental Health Care Plan Template
Practice Nurse Mental Health Online Learning
- Available on the BDDGP Mental Health page - provided by APNA
Allied Health and Dental Care Initiative
As well as the following documents, Allied Health and Dental Referral forms (effective November 1 2007) can be found under the Referral Forms & Templates section.
- Medicare items for allied health services for people with chronic conditions and complex care needs (download)
- Medicare items for dental care for people with chronic conditions and complex care needs (link)
- Eligibility criteria for allied health professionals providing new Medicare services (download)
- Answers to some frequently asked questions about the Medicare allied health and dental care initiative (download)
About the Incentives
Asthma
New! The National Asthma Council have a range of asthma managment tools on their 'managing asthma' page.
- Asthma Management Handbook 2006
- Asthma Cycle of Care
- Asthma Personal Action Plan
- Montelukast in Asthma
- The Asthma Foundation
- Lung Health
- Global resources in allergy (GLORIA)
- Australian Asthma & Respiratory Educators Association
- Australian Centre for Asthma (ACAM)
Cervical Cytology
- NHMRC Guidelines for the Management of Asymptomatic women with Screen Detected Abnormalities - March 2006
TIA/Stroke
- Article: How Likely is Stroke after TIA?
- Clinical Guidelines for Stroke and TIA Management: guides for General Practice
