When should GPs use a care plan?
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When should GPs use a care plan?

Chronic conditions like cancer, diabetes and cardiovascular disease are on the rise and they take a considerable amount of time for GPs to treat and manage on an ongoing basis. 

The Australian Government, via Medicare, has implemented GP Management Plans (GPMPs) to help GPs coordinate care for patients with chronic conditions or terminal illness. 

Care plans can be a valuable tool to help GPs manage the time spent on their patients with chronic conditions, and also to empower patients to take responsibility for their health outcomes. 

When to use a care plan 

To qualify for a GPMP, the patient must have a chronic medical condition, which has been, or is likely to have been, present for at least six months. While there is no list of eligible conditions, GPMPs are designed for patients who require a structured approach to chronic conditions requiring ongoing care. 

The GP providing the plan needs to have been the patient’s primary practitioner for at least the previous 12 months in the same practice, and be likely to provide the majority of services for the next 12 months. 

The plan must: 

  • Identify the chronic condition and care needs
  • Set out the services to be provided by the GP
  • List the actions patients can take to also help manage the condition

Patient participation is a crucial part of any care plan. The plan must have the agreement of the patient before it can proceed, a copy of the plan must be offered to the patient, and the plan must be reviewed regularly between the GP and patient, roughly every three months. 

A multidisciplinary team is not necessary for GPMPs as multidisciplinary teams are provided for under Team Care Arrangements  

When to claim 

GPs can claim for the preparation of a GPMP once every 12 months, and a review once every three months, provided the above criteria is met. Practitioners can provide services more frequently in exceptional circumstances, such as when there is a significant change in a patient’s condition, and needs to be clearly highlighted in the patient file. A review at least every 6 months is recommended.  

When to NOT use a care plan 

GPs cannot claim under a GPMP if they have been caring the patient for less than 12 months, or if the patient does not have an eligible chronic or terminal condition. GPs also cannot claim if they have not received the patient’s agreement to proceed with the plan, or if they have not offered a copy of the plan to the patient. 

Eligible patients include anyone in the community, as well as private in-patients of a hospital who are being discharged, and private in-patients who are residents of aged care facilities. Patients who are ineligible include public in-patients of a hospital and care recipients in a residential aged care facility. 

It is important to note penalties do apply if care plans are claimed incorrectly, so be sure to check the details before claiming.

Making the most of care plans for your patients and your practice 

While there may be a few hoops to jump through, care plans are an effective way to manage the care of patients with chronic or terminal illnesses. Care plans provide a structured plan for treatment and involve patients in their ongoing treatment, which can greatly improve health outcomes.