Use this guide on how you can effectively incorporate Chronic Disease Management (CDM) in your practice and how you can utilise your whole team for an effective CDM workflow
This workflow is broken into two key areas:
Opportunistic patient engagement - Identifying patients with upcoming appointments for CDM services.
Proactive patient engagement - Proactively looking at patient eligibility lists and booking patients in for appointments.
This guide will show you how to use both key areas and combine them into one full CDM workflow that involves your whole practice team. We will highlight how each role can use Cubiko data in the CDM workflow and how you can incorporate the QuickCheck function.
The roles included in this workflow are:
- Practice Managers/Management team
- Reception team
- Nursing team
- Practitioners and Doctors
Add our "Chronic Disease Management workflow" to your MyDashboard and share it with your team! This dashboard template highlights all of our key CDM metrics!
The sections included in this article are:
1. Chronic Disease Management Overview
- CDM timeline example
- How we identify patients as eligible for service opportunities
- Management and Reception team: Print off a daily list for Practitioners to identify patients coming in for an appointment today with potential service opportunities
- Nurses can identify patients coming in for the day ahead who may be eligible for nursing item numbers (10997 and 10987)
- Possible service opportunities today list for Practitioners (MyCubiko)
4. Using the metrics and data in your practice: Proactive patient engagement
- Item optimisation list for the Nursing team
5. CDM reports and forecasting
6. Additional resources and tools
1. CDM timeline
2. Understanding the metrics
Eligibility is based on patient demographics and previous billings of face-to-face, telehealth, telephone and non-VR item numbers at your practice. Vaccine eligibility is based on the immunisation history on the patient file at your practice.
- Item 721 Preparation of a GP Management Plan (GPMP): Eligibility is based on historical billings at your practice. This will exclude patients who have had item 721 billed in the past 12 months and those who have had item 732 (GPMP/TCA review) in the past 3 months.
- Item 723 Coordination of Team Care Arrangements (TCAs): Eligibility is based on historical billings at your practice. This will exclude patients who have had item 723 billed in the past 12 months and those who have had item 732 (GPMP/TCA review) in the past 3 months.
- Item 732 Review of a GP Management Plan or Coordination of a Review of Team Care Arrangements: Eligible patients who have had an item 721 (GPMP) or 723 (TCA) billed at your practice in the past 12 months and based on historical billings may be eligible for an item 732 (GPMP/TCA review). This excludes patients who have had an item 732 in the past 3 months or those who have had an item 721 or 723 in the past 3 months.
- Item 731 Contribution to a Multidisciplinary Care Plan, or to a review of a multidisciplinary care plan, for a resident in an aged care facility: Eligible patients have had item 731 billed at the practice, but not in the past 3 months.
- Potential patients for new CDM care plan: Eligibility is based on patients with an underlying condition (listed in the patients' active past history and observations) who have either never had a care plan or have not been billed for a care plan in the last two years. Broadly, our search function looks at Blood cancer diagnosis (within the last 5 years), Bone marrow transplants (within the last 2 years), Chronic liver disease, Chronic renal failure, Coronary heart disease or failure, Diabetes, Haemoglobinopathies, High BMI, Neurological condition, has transplant and immunosuppressant and Non-haematological cancer diagnosed in the last year.
- Item 10997 Provision of monitoring and support for a person with a chronic disease by a practice nurse or Aboriginal and Torres Strait Islander health practitioner: Eligibility is based on the patient's billing history at the practice and has had items 721, 723 or 732 billed in the past 12 months. This excludes patients who have had 5 or more 10997s this calendar year
Further information about patient eligibility for Chronic Disease Management (CDM) item numbers such as 721 and 723 can be found on the Department of Health website here.
3. Using the metrics and data in your practice: Opportunistic patient engagement
Management and Reception team: Print off a daily list for Practitioners to identify patients coming in for an appointment today with potential service opportunities
To navigate to this metric, go to Clinic Insights > Today's clinic metrics > Possible service opportunities today
Please refer to our knowledge base article "Possible service opportunities today" for more detailed information on filters and key components of the full metric.
Management and/or Reception can Print this list each morning for Practitioners!
The Practitioner can then make the clinical decision to book the patient in for a CDM service, communicate to the reception team and the reception team can schedule the patient!
Download our Doctor Direction Sheet to help communicate with your reception team what appointments you'd like patients to be rebooked for.
1. The default date range will be for today, if you a printing ahead use the date filter to amend.
2. Use the "Next appointment with" filter to select the practitioner you would like to print the list for.
3. Scroll down on the summary tab to the "Appointment of patients with opportunities" list and click the "Print preview" button in the filters sidebar on the left-hand side.
*Use the filters to apply any other particular filters for your list before printing. You can also use the tabs at the top of the page to print individual tables for each service opportunity.
You can also use Cubiko's QuickCheck appointment feature to check the eligibility of these potential CDM items for the day ahead through Medicare! See more here - Quickcheck.
If you run this daily, you can ensure the patient is eligible not just at your practice, and this result will appear in the pop-out window for your practitioners!
Nurses can identify patients coming in for the day ahead who may be eligible for nursing item numbers (10997 and 10987)
Check and Print this list each morning to identify patients coming in each day that may be eligible for nursing item numbers.
1. The default date range will be for today; if you are printing ahead, use the date filter to amend.
2. Use the tabs at the top of the page and select "Nurse items"
3. Here, you will find a table for each item number. Use the relevant item you want to identify. Note both of these tables will tell you how many items you have remaining to bill the calendar year and also the last date you billed this item for the patient!
3. Click the "Print Preview" button in the filters sidebar.
*Use the filters to apply any other particular filters for your list before printing
Possible service opportunities today list for Practitioners (MyCubiko)
Practitioners with access to MyCubiko can access the full list of their possible service opportunities today and pop this out into a sidebar!
This table shows a detailed breakdown of all of the possible item number service opportunities that the patients you are seeing today may be eligible for.
Use the Open new window button to pop this out into a list in a window that you can drag and resize and have running next to your practice management software.
TOP TIP! Please note the pop-out window session will automatically expire after 12 hours!
You can also use Cubiko's QuickCheck appointment feature to check the eligibility of these potential CDM items for the day ahead through Medicare! For more information on QuickCheck, click here.
If this check is done daily, you can ensure the patient is eligible, not just at your practice, and this result will appear in the pop-out window above under "Verified eligibility".
4. Using the metrics and data in your practice: Proactive patient engagement
To navigate to this metric, go to Clinic Optimisation > Item Optimisation
The Item Optimisation cabinet looks at your whole database of patients with a potential service opportunity inclusive of those with an appointment and without a future appointment.
Patient eligibility for this cabinet is the same as used in the Possible service opportunities metric.
Use the cabinet to identify a list of patients potentially eligible for Chronic disease management services, review the list with the patient's practitioner and proactively contact these patients to schedule appointments to have the services completed.
1. Identify the service opportunities items you would like to extract patient lists for
This cabinet is broken down into categories. You will find all of your CDM opportunities under the "Patients eligible for GPMPs, TCAs, MCPs and reviews" section.
And your 10997 opportunities under the "Patients eligible for Nurse items".
2. Once you have selected the item, click through to filter your patient list
By clicking into an item heading, you will find detailed information on potential patients for each service and a full list of patients:
Use your filters to identify patients with upcoming appointments over a period of time OR "No appointment booked"
You can then filter the list down via Practitioner:
Change the billing frequency and use the toggles to filter the list to look at:
Active patients with 3+ appointments in 2 years and choose to Include or remove RACF patients, patients under 18 years old, and MyMedicare registered patients.
3. Export your list to discuss with the relevant Practitioner
Once you have applied the relevant filters click the small download arrow on the top right-hand side of the patient list. This will export your filtered list into a CSV format. You can then select your download on your computer and print this list for review with the Practitioner.
4. Contact the patients to schedule an appointment
Be sure to use our forecasting tool below to ensure you have the capacity to book these patients in for these services. You may choose to contact patients via:
- Bulk SMS - Our patient lists in Cubiko provide the INTERNAL ID, which can be used by third-party software applications that integrate with Best Practice, to enable sending of SMS to these patients (such as Automed and HotDoc). For more information on how to download a .CSV file from Cubiko, click here.
- Letter
- Phone call
TOP TIP! Before booking the patient for an appointment, you can use our QuickCheck patient search function to ensure the patient is eligible to be billed and not had this service performed at another practice. Click here to find out more!
5. CDM reports and forecasting
Review utilisation and capacity
Now it’s time to book your patients in for appointments. But before we start patient outreach it’s important to make sure that your practice has the capacity and appointment availability to book these patients in for these services. The last thing you want is to contact patients asking them to book an appointment, but not have any availability in the appointment book.
Use the following metrics found via Clinic insights > Future clinic metrics to look ahead at utilisation and unbooked appointments:
CDM billings
Track the progress of your CDM billings by using our Total CDM billings report.
This metric can assist in tracking your Chronic Disease Management (CDM), Health Assessment and Nurse items revenue. You will also find here your "CDM opportunity" which shows the potential for Chronic Disease Management (CDM) billings for items 721, 723, 732 and 10997, based on patient eligibility from Item Optimisation.
To navigate to this metric, go to Past Clinic Metrics > Total CDM billings. It is also shown in our Practice billings summary cabinet.
CDM fulfillment
Look at the current fulfilment of CDM opportunity by Practitioner.
To navigate to this metric, go to Item optimisation > Potential new CDM patients
The percentage is derived from RACGP active CDM patients over sum of RACGP active CDM patients and total CDM opportunity. Only active practitioners are included.
Additional resources and tools
- Further information about patient eligibility for Chronic Disease Management (CDM) item numbers such as 721 and 723 can be found on the Department of Health website here.
- Download our CDM claiming cheat sheet from our website here.