Supporting nurses in primary health care 1300 303 184 [email protected].

Supporting nurses in primary health care

www.apna.asn.au1300 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

22% CVD

10% CRF

68% with diabetes have CVD or CRF

Mortality rate in Indigenous & socioeconomic disadvantaged groups

CVD, Diabetes & CRFAIHW 2014Cardiovascular disease,

diabetes & chronic kidney disease: Australian facts: prevalence & incidence

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

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

Acknowledge Person

Nurse Case Managers

Ongoing contact

Coordinating care

Disease surveillance

Independent of GP

GPN can be TCA member

Person Centred Medical Home

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

Forward Planning

Business ModelConsultations Item Number GP Time GPN Time Billing

GPMP 721 10 45 144.25

TCA 723 15 114.30

Reviews 732 30 45 432.30

GP Consults 23 80 296.40

GPN Monitoring 10997 75 60.00

ECG 11700 31.25

Bulk Billing 10991 238.70

TOTAL year 120 180 $ 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