Planning – making a difference
Understanding risk factors can help patients identify the lifestyle changes needed to make a positive difference. While conducting a health assessment, the GP team member can discuss interventions with the patient. Once agreed, and where appropriate, the interventions can then be summarised on a management plan and discussed in subsequent consultations. When interventions are jointly planned and negotiated, and information is shared between doctor and patient, the patient is more likely to be empowered and therefore committed to following the agreed plan.
Working with patients forms the basis of sustainable behaviour change as it involves patients in making decisions related to their health-improvement goals. The RACGP’s Putting prevention into practice (the Green book) (available at www.racgp.org.au/your-practice/guidelines/greenbook) includes a more detailed section on the principles of patient self-management that can be applied in this context.
A GP can utilise an MBS health assessment item to undertake a more comprehensive assessment of a patient with complex care needs. Health assessments also permit the needs of specific groups (eg. Aboriginal and Torres Strait Islander peoples, refugees and aged care residents) to be addressed in a targeted and culturally appropriate manner.
A GP Management Plan and Team Care Arrangement under Medicare’s Chronic Disease Management (CDM) GP services (formerly Enhanced Primary Care) may be appropriate for patients with a chronic or terminal medical condition and complex care needs. These act as comprehensive, longitudinal plans for patient care. While they are not appropriate for patients who are merely ‘at risk’ of disease, they can be an important tool for managing risk factors and interventions for those patients who already have chronic medical conditions and complex needs. The review of care plans is critically important as it provides an opportunity to review their implementation and effectiveness with the patient.
Refer to Chapter 5 for information and links to MBS items and templates that can be used for SNAP, such as a healthcare assessment and a chronic disease management plan.