CPD Course: Identifying Patients for Chronic and Complex Disease Management. EA, RP, MO.

Course Title

Identifying Patients for Chronic and Complex Disease Management. 0.5 EA, 1 RP, 5 MO.

Overview

This course equips General Practitioners (GPs) with the skills to identify patients eligible for chronic and complex care management services. It includes understanding key Medicare items, conducting comprehensive patient assessments, and engaging patients in relevant care plans to improve health outcomes.

Learning Objectives

By the end of this course, participants will be able to:

1. Understand eligibility criteria for Chronic Disease Management (CDM) services.
2. Use tools like AUSDRISK and Older Person’s Health Assessment protocols effectively.
3. Evaluate patient records to identify opportunities for CDM services.
4. Develop and monitor individualized care plans, including GP Management Plans (GPMPs) and Team Care Arrangements (TCAs).
5. Engage patients in preventive and ongoing care activities, enhancing compliance and outcomes.

Modules and Time Allocation

Module 1: Reading About Eligibility (0.5 Hours – Educational Activity)

This module provides foundational knowledge to understand patient eligibility criteria for key Medicare services:

Key Topics:

1. Eligibility for Care Plans:
   • Requirements for a GP Management Plan (GPMP) and Team Care Arrangements (TCAs).
   • Definitions of chronic conditions (e.g., conditions lasting 6+ months or terminal conditions).
   • Understanding the role of Medicare item numbers in chronic care coordination.
2. AUSDRISK Assessment:
   • Overview of the Australian Type 2 Diabetes Risk Assessment Tool.
   • Identifying patients at risk using AUSDRISK scores.
   • Integrating AUSDRISK as part of preventive care for eligible patients.
3. Medicare Item 10997:
   • Guidelines for Practice Nurse-led follow-up services.
   • Understanding the scope of allowable activities (e.g., monitoring, education, and care plan reviews).
   • Annual service limits and billing rules.
4. 75+ Assessments:
   • Eligibility criteria for older persons’ health assessments.
   • Key components, including physical, psychological, and social health evaluations.
   • Importance of preventive care and timely assessments.

Module 2: Looking Up – Reviewing Performance (1 Hour – Reviewing Patient Records)

In this hands-on module, participants will apply their knowledge to identify eligible patients:

Key Tasks:

1. Evaluate Medical Records:
   • Review the medical records of patients:
     • Booked for the next 1-2 weeks to proactively identify opportunities for chronic care services.
     • Seen in the preceding 1-2 weeks to ensure no eligible patients were missed during recent consultations.
2. Categorize Patients:
   • Determine eligibility for the following services:
     • Chronic Disease Care Plans (CDM Plans).
     • AUSDRISK Assessments for Type 2 Diabetes Risk.
     • 75+ Health Assessments for older adults.
     • Practice Nurse Follow-Ups (item 10997).
3. Document Findings:
   • Maintain a structured list of identified patients, specifying:
     • Eligible services.
     • The next step is to engage these patients in care plans or assessments.
4. Coordinate with Team Members:
   • Share findings with practice nurses and allied health professionals.
   • Develop an action plan to address identified patient needs.

Module 3: Measuring Outcomes (5 Hours – Measuring Outcomes)

This module focuses on evaluating the success of identifying and engaging patients in chronic care services:

Key Metrics:

1. Patient Identification:
   • Measure how many eligible patients were identified during the review process.
   • The desirable number of total patients reviewed is 150.
2. Service Engagement:
   • Track how many identified patients received recommended services:
     • Care Plans.
     • AUSDRISK assessments.
     • 75+ Assessments.
     • CDM follow-ups (item 10997).
3. Outcome Reporting:
   • Compile a report summarizing:
     • Total patients reviewed.
     • Number of patients eligible.
     • Services successfully delivered.
   • Use these insights to optimize future processes and improve patient care delivery.
4. Peer Discussion:
   • It is expected and highly desirable that a GP undertaking the activity discusses the Reviewing Performance and Measuring Outcomes with their peers to gain insights and enhance care strategies.

Assessment and Certification

At the end of the course, participants will complete a brief self-evaluation task. This is a reflective exercise, and no records need to be kept.

Self-Evaluation Task:

1. What did I learn about identifying eligible patients for chronic care services?
2. How confident do I feel in using tools like AUSDRISK and 75+ assessments?
3. Were there any challenges in reviewing patient records? How can I address them?
4. How many patients did I successfully identify and engage in services, and what can I do to improve?
5. How has discussing outcomes with peers helped refine my approach to patient care?

Certification:

• Certificates issued for:
  • 0.5 hours Educational Activity (EA).
  • 1 hour Reviewing Patient Records (RP).
  • 5 hours Measuring Outcomes (MO).

Course Delivery

• Fully Online: Participants can access the course content at any time from any device connected to the internet.

Technical Requirements

• Device Requirements: Access to a computer or mobile device with internet connectivity.

Certification

• Certificate of Completion: After reviewing all course sections, participants can download a certificate to encourage participation and acknowledge their learning.

Volunteers proudly run this site, and we operate without profit. The ads you see help cover our technical expenses. If you enjoy our courses and find them helpful, consider buying us a coffee. You can also support us by sharing our site with your friends. Every bit of help keeps us going! BUY ME A COFFEE

Where can you find your Certificate?

More free resources for General Practice at our main website: https://generalpracticetraining.com.au/