Programs - Chronic Disease Management

Asthma

The Asthma Incentive consists of the following components;

• Sign-on Payment: One-off payment to PIP practices that implement a cycle of care for patients with moderate to severe asthma.

• Service Incentive Payment: Payment to practitioners working within a PIP practice who complete an asthma cycle of care for patients with moderate to severe asthma, payable once per year per patient.  

Asthma Cycle of Care Items for patients with moderate to severe asthma - a minimum of 2 Asthma related consultations and provision of Asthma Action Plan: -

2546      Level B        

2552      Level C        

  2558      Level D         

SIP $100

Note: the incentive number is entered instead of the routine consultation item number    

Please click here to access Asthma Cycle of Care: Completing the Asthma Cycle of Care - A guide for General Practitioners    

Resource - Asthma Cycle of Care

Chronic Obstructive Pulmonary Disease (COPD)

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) is a major cause of disability, hospital admission and premature death. More than 600,000 Australians are estimated to have COPD and, as the population ages, the burden of COPD is likely to increase. In Australia, COPD is the fifth greatest contributor to the overall burden of disease accounting for 3.6% of disability-adjusted life years (DALY) in 2003.

Having COPD can be a stressful life event and apart from the physical symptoms, a patient may feel depressed, anxious, worried, irritable, isolated and confused. Patient support is all about helping to manage and control symptoms, overcome negative feelings and build confidence again. Smoking is the most important risk factor for COPD so working with patients to prevent the onset of COPD is also important. 

The challenges posed by the increasing burden of chronic diseases on health systems require development of health service models that have a fundamentally different orientation toward anticipatory and proactive care in addition to acute reactive care not only for individuals with a particular chronic condition (like COPD),but also for individuals with multiple morbidities. 

Experts have articulated domains for system reform in the Chronic Care Model. These include:

1. Delivery System Design (e.g. multi-professional teams, clear division of labour, acute vs. planned care);
2. Self Management Support (e.g. systematic support for patients / families to acquire skills and confidence to manage their condition);
3. Decision Support (e.g. evidence-based guidelines, continuing professional development programs) and,  
4. Clinical Information Systems (e.g. recall reminder systems and registries for planning care). Much can be done to improve quality of life, increase exercise capacity, and reduce morbidity and mortality in individuals who have COPD.  

Your practice should consider creating a register for COPD patients and systematically recalling them to provide GPMPs and TCAs in relation to their condition – you can refer to the COPD guidelines below to assist.  

The key recommendations to consider are summarised as (COPDX): 

Confirm diagnosis,

Optimise function,

Prevent deterioration,

Develop a self-management plan and manage exacerbations. 

The COPD-X Plan: Australian and New Zealand Guidelines for the management of
Chronic Obstructive Pulmonary Disease 2008

Resource - November 2008 COPDX

These guidelines have been developed by the Australian Lung Foundation and the
Thoracic Society of Australia and New Zealand as part of a national COPD program.

This Australian and New Zealand guideline is written as a decision support aid primarily for general practitioners and other primary health care clinicians managing people with established COPD. It is regularly updated as new evidence is published. 

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