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Medical care of older persons in residential aged care facilities (Silver Book)

Medicare item numbers

Until November 2000, Medicare rebates were available only for GP consultations at the RACF. Since then, items have been introduced progressively to better remunerate GPs, and improve multidisciplinary care for residents. The Medicare Benefits Schedule (MBS) lists current item descriptors and rebates available for medical services provided to residents for the following services:259

  • GP consultations in RACFs

  • GP comprehensive medical assessment (CMA)

  • GP organising or participating in multidisciplinary case conferences

  • GP contribution to the resident's care plan

  • GP participation in residential medication management review

  • allied health and dental services on referral from a GP.

Figure 3 provides a summary of how these MBS items can be used by GPs providing care for residents.

Consider the following when deciding on how to organise and use Medicare items at a RACF:

  • What is the likely workload within the facility (how many patients are likely to need a CMA or case conference per week, month or year)? Use a reminder/recall system to schedule reviews

  • What is the range of complexity or special needs of residents? Identify and target residents who will benefit most from a CMA, case conference or specific types of services

  • How much available time do GPs and facility staff have to contribute to the CMA and care planning?

  • What is the range and level of multidisciplinary expertise available? Identify RACF staff and external service providers with specific skills, eg. for assessment, advance care planning and treatment.

General practitioner attendances at a RACF: The purpose of MBS rebates for GP consultations in RACFs is to reimburse GPs for face-to-face patient consultation time, plus travel time. The MBS rebate is equivalent to the corresponding item in the GP's rooms, plus an amount divided by the number of patients seen (up to six patients), and then a set amount per patient for seven or more patients.

Comprehensive medical assessment: An up-to-date health and medical summary for all patients including those in residential aged care is a RACGP accreditation standard. General practitioners can be remunerated to undertake a CMA annually for new and existing permanent residents in high and low care facilities. The CMA may highlight particular issues such as an immediate medical need, problems with medication management, and needs for specialist referral or allied health services. A sample 'Comprehensive medical assessment form' is provided in Tools 10, or at http://www.health.gov.au/internet/wcms/publishing.nsf/ Content/health-medicare-health_pro-gp-cmarach.htm.

General practitioner contribution to a resident's care plan: RACFs are required and receive funding to develop care plans for permanent residents. RACF care plans focus on personal and nursing care rather than medical care. General practitioners may contribute to these care plans at the request of RACF staff. From 1 July 2005 new chronic disease management (CDM) Medicare numbers replaced EPC multidisciplinary care planning items which will be withdrawn on 1 November 2005. The new CDM item 731 retains similar provisions to the old item 730 for GPs to contribute to the preparation and/or review of care plans for residents of aged care facilities. Item 731 can be claimed at 6 monthly intervals. It involves review of the plan with the addition of any relevant medical information, eg. instructions for after hours care, need for referral to allied health or dental services. It is also an opportunity for GPs to enquire if advance care planning has been discussed.

General practitioner RACF case conference: Case conferences support multidisciplinary management of residents with complex care needs, when a condition has been present or is expected to last for at least 6 months, or is terminal. Medicare Benefits Schedule items may be claimed for up to five case conferences for an individual resident in any 12 month period when there is participation by the GP and at least two other care providers. A sample 'GP RACF case conference record' is provided in Tools 11.

Referrals for Medicare rebated allied health and dental services: When a GP has contributed to a care plan for a resident and item 731 (or 730) has been claimed, the resident is eligible to access Medicare rebatable items for allied health and dental services on referral from their GP. Eligibility is determined for a resident with a chronic condition and complex care needs managed by a GP and identified in the resident's care plan. The dental problem must be adding significantly to the seriousness of the chronic condition identified in the care plan. Up to five allied health services per year (in total not five per service type) and three dental services are available. The allied health professional or dentist must register as a private provider with the Medicare Australia. A referral to the allied health practitioner or dentist is made using the EPC Program referral form for allied health services, available at http://www.medicareaustralia.gov.au/providers/incentives_allowances/ medicare_initiatives/allied_health.htm.


Figure 3. How MBS items relate to a resident's medical care

 Admission to the RACF or change in medical status

RACF care plan


Comprehensive medical assessment (item 712) once every 12 months


Provide CMA summary report to RACF and resident. Summary report to include:

  • List of principal diagnoses/problems

  • Allergies and medication intolerance

  • Current medication

  • Issues for medication management review

  • Other services/treatment required

  • Immediate action required

Update care plan to include information from CMA summary report and request GP to review care plan


RMMR (item 903)

GP contribution to the RACF care plan (item 731) up to 4 times per year


Referral to allied health (item 10950, 10952, 10954, 10956, 10958, 10960, 10962, 10964, 10966, 10968, 10970) up to five allied health services per year


Referral to dental care (item 10975, 10976, 10977) up to three services per year

 Change in resident medical status or 6 month review

RACF can organise and coordinate a case conference to include GP



GP participates in case conference (item 775, 778, 779) up to five per year in total
OR
GP organises and coordinates case conference (item (item 734, 736, 738) up to five per year in total

Update care plan to include information from the case conference and request GP to review care plan



GP contribution to a care plan (item 731)


Referral to allied health (item 10950, 10952, 10954, 10956, 10958, 10960, 10962, 10964, 10966, 10968, 10970) up to five allied health services per year


Referral to dental care (item 10975, 10976, 10977) up to three services per year care plan

 Routine resident medical care


GP consultation at a RACF (item 35, 43, 51)


Residential medication management review (RMMR): The RMMR enables the GP and pharmacist to review the medication needs of a new or existing resident. Table 16 gives a GP checklist for a RMMR. The checklist and up-to-date forms can be accessed at http://www.health.gov.au/internet/wcms/publishing.nsf/Content/health-epc-dmmrqa.htm.


Table 16. GP checklist for conducting a RMMR

1. Determine the clinical need for a medication management review. This step is not necessary for new residents as they are entitled to a residential medication management review on admission

Mandatory for existing residents

2. Explain RMMR to resident/representative and obtain consent

Mandatory

3. Initiate the RMMR and collaborate with reviewing pharmacist regarding the pharmacist's component of the review. The initial discussion with the reviewing pharmacist should cover:

  • a communication protocol

  • exceptions to a postreview discussion

  • clinical information relevant to the pharmacist's component of RMMR

Mandatory

4. Postreview discussion with the reviewing pharmacist should cover:

  • the findings of the pharmacist's review

  • medication management strategies

  • means to ensure the strategies are implemented and reviewed, and

  • any issues for implementation and usual follow up

Mandatory unless:

  • no recommended changes

  • minor changes

GP and pharmacist agree on need for case conference

5. Consultation with the resident to discuss the outcomes of the review and proposed medication management strategy and to gain the resident's agreement to the plan

Mandatory

6. Finalise and prepare written medication management plan

Mandatory

7. Offer a copy of the plan to the resident/or resident representative:

  • copy for the resident's records

  • copy for the nursing staff of the aged care home

  • discuss the plan with aged care nursing staff if necessary

Mandatory

8. Bill the resident for the service

Item 903

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