Chronic disease management

Activity ideas:

1. Prompt your patients to register in advance of their appointments
   • Send an SMS to all patients with a scheduled Chronic Disease Management Plan encouraging them to register with your General Practice before their appointment using Medicare Online or print and complete a MyMedicare Registration form to bring to their appointment, or
   • Invite patients to attend their appointment early to complete a MyMedicare Registration Form in the practice waiting room.
2. Encourage your patients to register at their next appointment
   • Check each patients’ MyMedicare Registration status with your practice when they present for their appointment or the day before their appointment
   • Provide a MyMedicare Registration QR code or MyMedicare Registration form when patients present to the practice, and encourage them to complete their registration, or discuss registration as part of their Chronic Disease Management appointment
   • Have your practice nurse or Aboriginal Health Practitioner assist the patient with completing the registration for as part of their Chronic Disease appointment. This provides an opportunity for a conversation about expectations of an ongoing care relationship so that the practice can support the patient’s health journey in the long term.

Activity ideas:

1. Consider and develop a method for how your practice will approach scheduling review appointments. You may decide to adopt a standard 3-month review or 6-month review approach or require the clinical team to advise on the review timelines informed by their clinical judgement on a case-by-case basis.
2. Develop workflows for reception – to ensure that as the patient is handed over to reception before they leave your practice reception has an action to schedule their next appointment, understands the timeframe for review to inform scheduling, and communicates the appointment time and date clearly to the patient (SMS, or reminder card, or other).
3. Develop a process for appointment reminders in leadup to review appointments – frequency (e.g. 1 week and 24 hours) and modality (phone call or SMS) to ensure your attendance rates for review appointments remain high. Include message for patient to check Medicare Online to ensure they are registered for MyMedicare with your practice, document any questions to bring to the appointment.

Activity ideas:

1. Review your process and strengthen how you document priorities and actions due for the next review appointment in the patients’ medical record in your practice software as part of all Chronic Disease Management Plans and Reviews. For example, document any:             
   • Outcomes, goals or targets the patient has for their review appointment
   • Education or points of discussion planned for the review appointment
   • Tests or pathology due that need to be scheduled
   • Referrals that need to be completed.
2. Communicate the importance of the review appointment with your patient and their carers (if appropriate) including:
   • Emphasize the importance of the review plan focusing on actions for the patient and why the review is needed with your patient at the conclusion of the appointment
   • Provide patient with a printed copy of the care plan and review appointment plan 
   • Outline expectations and processes to re-schedule review appointment ahead of time.
3. Develop messaging for patients about the benefits of proactive care, care when you are not acutely unwell, or keeping you well. Develop communications to support this in your practice, for example:
   • Waiting room posters targeting CDM patients
   • Talking points for the practice team to reinforce the importance of reviews and attending for care when patients are not acutely unwell.

Activity ideas:

Document the process for how to manage cancellations or missed review appointments. As part of this process consider:

1. How is the cancellation or non-attendance documented? For example, will your practice flag the patient, or retain a list of patients that need to be re-scheduled?
2. Who needs to be notified? (e.g. Nurse or Aboriginal Health Practitioner with responsibility for Chronic Disease coordination, and the patients usual GP)
3. What are the standing arrangements for re-scheduling CDM review appointments? For example, does your practice aim to re-schedule within 2 weeks of the cancellation or follow up non-attendance with a phone call to reschedule as a standard operating procedure?
4. Are there any data searches that need to be completed at regular intervals to identify any patients that may have missed their appointment but not been re-scheduled? For example, you could run a report from your clinical practice software for patients that have not had a review in more than 6 months and provide this list to a Nurse or Aboriginal Health Practitioner with responsibility for Chronic Disease coordination for review and action to check for any patients that have missed their scheduled review.

1. Engage your practice team to inform them about MyMedicare and the changes to Chronic conditions management:
   • Team meeting or quick lunch catch up to communicate the changes
   • Post an update in the practice staff room
   • Send an email to the practice team with the critical information

1. Talking points for your practice for MyMedicare are included below for you to adapt and share. If you plan to discuss these in an open forum with your team, you may want to share these in advance, and pose some general questions such as:
   • What could be some of the benefits of increasing MyMedicare participation for our practice?
   • What does/could MyMedicare mean for our practice and patients?
   • How does a stronger relationship with patients fit with our practice business plan and strategy?
2. The MyMedicare GP Toolkit provides a good summary of the current benefits of MyMedicare for General Practices. The toolkit also includes a range of helpful resources your practice can use to communicate with patients.

1. A summary of CCM changes is included below for you to adapt and share. You may want to have a team discussion and pose some open questions such as:
   • How are these changes similar or different to current CDM care?
   • Are our practice nurses or Aboriginal and Torres Strait Islander health practitioners confident in care planning or is there more training or development we wish to plan for?
   • What is our ratio of care plans to care plan reviews at the moment? What changes would we need to make to conduct more regular reviews?
   • More considerations for planning are included in CCM Activity 1
2. More information is available at these links:
   • Chronic Conditions Management (CCM) MBS item changes
   • MBS Review Taskforce.

Resources proposing some team roles ideas and a blank template are provided to help you get started.

1. Explore roles and responsibilities with the practice team in a meeting or quick lunchtime discussions
2. Document agreed roles and responsibilities and communicate this with your team
3. Discuss and document how each team member will incorporate their responsibilities into their workday and work week
4. Schedule a time to review your documented roles and responsibilities
   • Check in with your practice team 4 weeks after publishing these for a quick reflection and to maintain momentum as people adapt to their new responsibilities
   • Review team roles and responsibilities at 3 months and make any changes or improvements based on lessons learned