What GPs need to know before creating a care plan  
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What GPs need to know before creating a care plan  

As Australia’s population ages, chronic conditions such as stroke, cardiovascular disease, and diabetes are becoming more common. As a result, we’re seeing an increased need for multiple consultations and ongoing patient management, which in turn puts extra pressure on GPs and Practice Managers.  

If a patient has a chronic condition, they may be eligible for services under a care plan: General Practitioner Management Plan (GPMP) or Team Care Arrangement (TCA).  

The Australian Government has implemented care plans to help practitioners coordinate the care of people with chronic conditions and encourage proactive and well-thought out care, including scheduled check-ins at regular intervals. 

Practitioners who can claim for care plans include: 

  • General Practitioners (GPs) 
  • Non-vocationally recognised medical practitioners (non-VR MPs)

Care plans also help record comprehensive, accurate and up-to-date information about a patient’s condition and treatment to help encourage the patient to take responsibility for their care, which is vital in the management of chronic conditions. 

Guidelines 

To qualify, chronic medical conditions need to have been present or likely to be present for at least six months, for example: Asthma, cancer, cardiovascular disease, diabetes, kidney disease, musculoskeletal conditions, and stroke. There is no list of approved conditions, they just need to meet this definition of ‘chronic’. 

Practitioners also need to have been the patient’s main GP in the same practice for a minimum of 12 months, and need to be likely to provide the majority of services over the next 12 months. 

Patients can include anyone in the community, including private in-patients of a hospital who are being discharged, and private in-patients who are residents of aged care facilities. 

Things to include in a care plan 

When preparing a care plan, GPs should explain the steps involved in preparing the plan to the patient, and record their agreement to proceed. 

The care plan must describe: 

  • The patient’s healthcare needs, health problems and relevant conditions
  • Management goals and actions for the patient
  • Treatment and services the patient will need
  • Arrangements for providing the treatment and services
  • Arrangements to review the plan (at least every 6 months is recommended) 

Once the patient agrees with the care plan, the GP must then offer them a copy and add a copy to their medical record. 

Preparing Team Care Arrangements 

Team Care Arrangements are for chronic conditions that require a multidisciplinary team. The GP must consult with a multidisciplinary team, which includes the patient’s eligible practitioner, and at least two other collaborating health or care providers, one of whom may be another medical practitioner. 

Each person in the team needs to provide a different type of ongoing treatment or service, although they don’t need to be Medicare eligible providers. A patient’s informal or family carer does not count as a healthcare provider. 

The GP must then explain the steps involved in developing the Team Care Arrangement with the patient, record whether the patient agrees to proceed, and discuss the multidisciplinary team who will contribute. 

The following must be recorded: 

  • Treatment and service goals for the patient 
  • Treatment and services being offered by collaborating providers 
  • What actions the patient needs to take 
  • A review of dates in the care plan

Once the GP has completed the document they must offer a copy of to the patient, share copies of the relevant parts of the document to collaborating providers, and add a copy of the document to the patient’s medical record. 

More information can be found on eligibility criteria and claiming here. 

Medicare obligations and penalties for non-compliance 

There are a few things GPs need to know before they create a care plan under Medicare. Rules are strict and penalties will apply if GPs are found to claim for care plans incorrectly through Medicare. 

Under the Health Insurance Act 1973, GPs are legally responsible for services billed to Medicare under their Medicare provider number or name. There are penalties for non-compliance under Medicare, so GPs must adhere to the guidelines. 

The penalties for incorrect claiming include fines as well as repayment of the full Medicare benefit, regardless of who claimed it. Serious cases, including fraud, carry stronger penalties. 

GPs should always check the requirements before claiming, to ensure the criteria is met. This will ensure they protect themselves, their practice, and their patients. 

More information on Medicare responsibilities and penalties for non-compliance can be found here.  

Supporting continuity of care and optimising patient outcomes 

Care plans are a great way to manage ongoing chronic conditions and get patient buy-in for treatment and lifestyle management. When used correctly, they can help reduce clinical burden, improve practice efficiencies, enhance patient-centric outcomes and support continuity of care in the long term.