Monash Division of General Practice
Chronic Disease Management
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Chronic Disease Management Program
The Division offers support to GPs and practice staff in all aspects of chronic disease management through practice visits, phone support, resource provision and continuing professional development activities. Assistance is available in relation to:

  1. Chronic Disease Management MBS Items (introduced on 1 st July 2005)
  2. Allied health and dental care MBS items
  3. Enhanced Primary Care MBS items for health assessments and case conferences
  4. PIP Incentives for Chronic Disease Management
    • Diabetes
    • Asthma
    • Cervical Screening
  5. Using clinical software for chronic disease management including the use of registers, recall and reminder systems
  6. Lifescripts Resources
  7. Patient education resources

 

Chronic Disease Management MBS items - GP Management Plans and Team Care Arrangements
The Chronic Disease Management MBS items were introduced in July 2005, a summary table is available.

The Division has developed a range of resources to assist practices with the new chronic disease management MBS items. These resources include a series of templates for the MBS tem numbers, both generic and disease specific templates. Other disease specific templates are being developed and will be added to the website as they become available.

Copies of the templates for downloading into clinical software are available under the IMIT resources section of the website. Microsoft (MS) Word Versions of the templates are available on the resources page of this site under Chronic Disease Management.

 

Allied Health and Dental Care MBS Items
For the latest update on changes to the Dental Care MBS Items, please contact the Division.

Health Assessments / Case Conferences
The Enhanced Primary Care (EPC) items for Health assessment and case conferencing were introduced in to the Medicare Schedule in 1999.
See also Aged Care section for information on services available to residents of aged care facilities.

Health Assessments
Health assessments (MBS Items 700 - 706) are available for patients 75 years and over and Aboriginal and Torres Strait Islander patients who are 55 years or older who are living at home and not in hospital or a residential aged care facility. To view resources for Health Assessments go to the Resources Section of this website under Health Assessments/Case Conferences.

Case Conferences
Case conferences (MBS Items 734 – 779) are available for patients with chronic and complex conditions requiring multi disciplinary care. To view resources for Case Conferences go to the Resources Section of this website under Health Assessments/Case Conferences.

 

45 Year Old Health Check MBS Item
On 1 November 2006 a new MBS item for a 45 Year Old Health Check (Item 717) was introduced into the Medicare Benefit Schedule. The aim of the health check is to assist with detection and prevention of chronic disease and to enable early intervention strategies to be put in place where appropriate. The item can be used by both vocationally registered and non-VR GPs, in either accredited or non-accredited practices.

Full details about the new item number are provided in the November 2006 Medicare Benefits Schedule. Medicare has also produced resources to assist practices which are available on the resources page of this website.

Chronic Disease Management PIP Incentives
In November 2001 the Commonwealth Government expanded the Practice Incentive Program (PIP) to improve earlier diagnosis and management of specific chronic diseases: diabetes, asthma and cervical screening. The Division is able to assist practices in developing sustainable systems for implementing and claiming these incentives.
(See also Mental Health and Practice Nurse sections of this site.)

Diabetes PIP

Asthma PIP

Cervical Screening PIP

Using clinical software for chronic disease management

See also IMIT section of website

Chronic Disease Management Toolkit CDROM
The Division has developed a Chronic Disease Management Toolkit in CD ROM format, which includes an extensive range of resources for health care providers as well as patient education resources. The current version of the CDROM includes 2 modules: asthma and diabetes. Further modules are to be added. Copies of the asthma module CD ROM can be obtained by contacting the Division.

Recall Reminder systems

Resources

A full range of resources related to Chronic Disease Management are available on the Resources page of this website.

Lifescripts Resources
‘Lifescripts’ is a new set of resources designed to assist GPs and practice nurses in providing lifestyle advice and support for behaviour change in relation to: smoking, nutrition, alcohol, physical activity and weight management. The resources have been funded by the Department of Health and Ageing and can be obtained free of charge from the Division.
Copies of the Lifescripts resources for downloading into Medical Director are available under the templates section of this website. Paper copies of the Lifescripts resource kits are available from the Division.

Patient Education Resources
The Division’s Chronic Disease Management Toolkit CD ROM provides an extensive range patient education resources on asthma and diabetes. Further modules and education resources are to be added to the CDROM. The CD ROM can be obtained by contacting the Division.

A range of patient education resources can also be accessed via the Victorian Government Better Health Channel and Health Translations Directory (see links).

Links

Australian Department of Health and Ageing - Provides information on the Department's policies, programs and services, including a section for health professionals.

Medicare Australia - Includes section for health professionals on Medicare Australia Programs.

Medicare Benefits Schedule - Medicare Benefits Schedule Online. From here you can search and browse through the Medicare Items or the Explanatory Notes contained within the Schedule. You can search by either the Number or Description of the Items or Notes or browse through the Categories.

Practice Incentives Program - Department of Health and Ageing site for information on the PIP.

Australian Division of General Practice - ADGP is the peak national body representing Divisions of General Practice. The site includes a clearing house of resources to support General Practice with the implementation of the CDM items.

Lifescripts - Information on the Lifescripts resources can be accessed via the ADGP website, including interactive templates for the Lifescripts assessments, prescriptions and guidelines.

Better Health Channel - For accessing information on health services throughout Victoria and a range of patient education materials , quality assured by the Victorian Government.

Health Translations Directory - Provides access to reliable translated health information via links to online multilingual health resources from government departments, peak health bodies, hospitals, community health centres and welfare agencies. Search by topic, by language, or both.

HealthInsite - HealthInsite is the Australian Government’s Internet-based gateway to quality-assessed health information providing access to over 10,000 information resources from quality assessed information partner sites. A useful feature is the page about materials for health professionals.

AIHW (Australian Institute of Health and Welfare) -The Australian Institute of Health and Welfare ( AIHW ) is a national agency for health and welfare statistics and information.

Department of Human Services – Victoria

Diabetes Links

International Diabetes Institute - The International Diabetes Institute provides a range of services for people with diabetes as well as education services for health professionals. The website provides access to a range of fact sheets and links to other diabetes websites.

Diabetes Australia - Diabetes Australia is a not-for-profit organisation providing support for people with diabetes. The website contains all the Diabetes Australia publications in printable form including multilingual information sheets and provides links to a range of national and international diabetes websites.

Diabetes Australia – Victoria - Diabetes Australia – Victoria is the peak consumer body representing people with diabetes in Victoria, providing support and information to the community about diabetes. The website provides information on support groups, events, NDSS outlets and information sheets.

Australian Diabetes Educators Association

Asthma Links

National Asthma Council Australia (NAC) - The NAC website contains all the NAC publications in printable form and is linked to a range of reputable national and international asthma and respiratory websites. Resources available on the NAC website include:

  • Asthma Management Handbook 2006
  • Spirometry Handbook
  • Asthma Cycle of Care Resources

Consumer Information sheets in a range of languages.

Asthma Victoria - Asthma Victoria offers support groups, asthma products, an extensive range of brochures and information sheets for consumers.

Victorian Asthma Health Educators Association - The Victorian Asthma Health Educators' Association (VAHEA) was formed in 1992 to provide support, professional development and networks for health professionals in asthma education. Listings of asthma educators by area can be downloaded from this site.

Australian Lung Foundation - The ALF site provides information for health care professionals and patient education leaflets.

Lung Health Promotion Centre at the Alfred Hospital - The Lung Health Promotion Centre provides education for health professionals in the evidence-based management of asthma, allergy and respiratory health.

QUIT - Provides information and resources to assist in smoking cessation .

Cervical Screening Links

PapScreen Victoria - The PapScreen site is for women seeking information of Pap tests and cervical cancer. A section for health professionals is also now available and a directory of pap test providers in Victoria.

Victorian Cervical Cytology Registry - The Victorian Cervical Cytology Registry website includes general information about the Registry. Health professionals can access up-to-date statistics on cervical screening and order resources on-line, and women can update their own contact details.

Victorian Cytology Service - VCS specialises in cervical cytology and is a not for profit organization. VCS Pap smear reporting provides a free service for women. The VCS Liaison Physician Dr Stella Heley is available to discuss cervical screening with practitioners either by telephone or through visits to practices, s he may be contacted at VCS on 9250 0300 or email sheley@vcs.org.au 

The Cancer Council Victoria - The Cancer Council website contains detailed information about how to prevent the various types of cancer, as well as information for people with cancer.

The Royal Women's Hospital - The Royal Women's Hospital Well Women's website has information about the Women's Health Program services at the hospital, including the 'Women's Health Information Centre', 'Sexual Health and Well Being', and 'Services for Older Women'.

National Cervical Screening Program - This government website has information about the policies in Australia for screening. A number of publications relevant to the program can be downloaded.