Ayr Medical Group

GP Management Plans & Team Care Arrangements

Patient information

• There are two types of plans that can be prepared by a General Practitioner (GP) for Chronic Disease Management (CDM): GP Management Plan (GPMP); and Team Care Arrangements (TCAs).
• If you have a chronic (or terminal) medical condition, your GP may suggest a GPMP.
• If you also have complex care needs and require treatment from two or more other health care providers, your GP may suggest TCAs as well.
• Your GP or practice staff must obtain your agreement before providing these plans.
• If a provider accepts the Medicare benefit as full payment for the service, there will be no out-of-pocket cost. If not, you will have to pay the difference between the fee charged and the Medicare rebate.
• If you have both a GPMP and TCAs prepared for you by your GP, you may be eligible for Medicare rebates for certain allied health services. It is up to a GP to determine whether you are eligible for these allied health services which must be directly related to the management of your chronic condition.
• The practice nurse can provide support and monitoring between visits to your GP.
• Your GP will offer you a copy of your plan.
• You and your GP should regularly review your plan/s.

 Chronic medical conditions

A chronic medical condition is one that has been (or is likely to be) present for six months or longer, for example, asthma, cancer, heart disease, diabetes, arthritis and stroke. There is no list of eligible conditions. However, these items are designed for patients who require a structured approach and to enable GPs to plan and coordinate the care of patients with complex conditions requiring ongoing care from a multidisciplinary care team. Your GP will determine whether a plan is appropriate for you.

GP Management Plan

A GP Management Plan (GPMP) can help people with chronic medical conditions by providing an organised approach to care. A GPMP is a plan of action you have agreed with your GP. This plan:

• identifies your health and care needs;
• sets out the services to be provided by your GP; and
• lists the actions you can take to help manage your condition.

Team Care Arrangements

If you have a chronic medical condition and complex care needs requiring multidisciplinary care, your GP may also develop Team Care Arrangements (TCAs). These will help Chronic Disease Management – coordinate more effectively the care you need from your GP and other health or care providers. TCAs require your GP to collaborate with at least two other health or care providers who will give ongoing treatment or services to you. Let your GP or nurse know if there are aspects of your care that you do not want discussed with other health care providers.

 Review of GPMPs and TCAs

Once a plan is in place, it should be regularly reviewed by your GP. This is an important part of the planning cycle, where you and your GP check that your goals are being met and agree on any changes that might be needed.

Referrals for allied health services

If you have both a GPMP and TCAs prepared for you by your GP, you may be eligible for Medicare rebates for specific individual allied health services that your GP has identified as part of your care. The need for these services must be directly related to your chronic medical (or terminal) condition. If you have type 2 diabetes and your GP has prepared a GPMP, you can also be referred for certain allied health services provided in a group setting.

Summary:

• A Medicare rebate is available for a maximum of five services per patient each calendar year. Additional services are not possible in any circumstances.
• If a provider accepts the Medicare benefit as full payment for the service, there will be no out-of-pocket cost. If not, the patient will have to pay the difference between the fee charged and the Medicare rebate.
• Patients must have a GP Management Plan and Team Care Arrangements prepared by their GP, or be residents of a residential aged care facility who are managed under a multidisciplinary care plan.
• Referrals to allied health providers must be from GPs.
• Allied health providers must report back to the referring GP.

Referral validity

A referral is valid for the stated number of services. If all services are not used during the calendar year in which the patient was referred, the unused services can be used in the next calendar year.

However, those services will be counted towards the five rebates for allied health services available to the patient during that calendar year.

When all referred services have been used, or a referral to a different allied health provider is required, patients need to obtain a new referral.

Note: It is not necessary to have a new GPMP or TCAs prepared each calendar year in order to access a new referral(s) for eligible allied health services. Patients continue to be eligible for rebates for allied health services while they are being managed under a GPMP and TCAs as long as the need for eligible services continues to be recommended in their plan.

FAQS for Patients

Many Australians are living with chronic diseases like diabetes, asthma, heart disease and arthritis. Talk with your doctor about preventing or managing chronic disease and ask how we can help you maintain your independence and stay as healthy as possible.

GP Management Plans

Our united and informed approach leads to improved patient health and well-being.

Your doctor and Practice Nurse will develop a plan designed to meet your needs. It will give you a co-ordinated approach to include the specialists and allied health practitioners who also care for you.

We see it as an integral part of the personal care we provide for our patients who are living with chronic medical conditions or terminal illness. It ensures both parties have a clear understanding of your very specific needs and provides thought out and well planned pathways to manage those conditions.  We make sure we look after our patients who those require multidisciplinary, team-based care from a GP and at least two other health or care providers.

Who will benefit from a GP Management Plan?

Any person with a chronic (long term) medical condition such as for eg:

• Diabetes
• Asthma
• Arthritis
• Cancer
• Heart Disease
• Osteoporosis
• Mental Health

How does it work?

Taking into account your medical history held at our clinic and other health records you can provide, together we identify the following:

• Your health priorities
• Actions you can take to help manage your condition
• Other health care and community services you need and provide the relevant referrals
• What results you would like from the plan to help with your chronic condition

What will Team Care Arrangements mean for me?

We will prepare any referrals you need.

Once it is determined you would benefit from other health care providers or allied health professionals being involved in providing treatment, a team care arrangement will be completed. With your consent, your doctor or practice nurse will ask the relevant allied health professionals to be part of your care plan.

Who are allied health professionals?

Any allied health worker such as a physiotherapist, dietitian, podiatrist, audiologist, diabetes nurse, occupational therapist, pharmacist, psychologist, psychiatrist or exercise physiologist.  Some of the allied health professionals we work with operate from our clinic rooms.

How many visits can I have with an allied health professional?

Patients with a GP Management Plan and Team Care Arrangement are eligible for 5 visits per calendar year to see allied health professionals.

Will it cost me anything?

GP & Team Care Plans are bulked billed by your GP at Ayr Medical Group so there will be no charge for these services.

Will it cost anything to see an allied health professional under my plan?

Once your GP Management Plan is in place you can access eligible allied health practitioners through the Medicare system. Some may choose to bulk bill you and others may charge you their standard private fee however the rebate you can claim through Medicare is higher than you would receive if claiming through a private health fund. Check with the health practitioner when you book.

I have my Plan, what happens next?

We have made it easy for you:

1. Keep your copy of your GP Management Plan and Team Care Arrangement in a safe place.
2. Book your appointments with your allied health teams.
3. Track how you are responding to the recommendations and healthcare services you receive
4. Book a review with your GP every 3-6 months to discuss your treatment. We will endeavour to contact you to remind you.