This case study focuses on an Indigenous patient. It gives examples of suitable CDM items for different health professionals providing coordinated health care.
Case study
A 52-year-old Indigenous patient presents with an infected foot that requires wound management and antibiotics.
Their medical history includes all of the following:
- Hypertension and high cholesterol.
- Mild renal condition.
- Myocardial infarction.
- Type 2 diabetes.
- Increasing circulation concerns with associated foot issues.
As well as this, they:
- have a family history of heart disease
- smoke
- have a poor diet
- seldom seek medical attention
- usually attend the clinic every 6 months for script renewals
- aren’t effectively managing their chronic conditions.
Actions to develop the care plan
There are steps to develop the care plan.
First visit
In this visit, you do all the following:
- Discuss your patient’s health issues.
- Outline the potential benefits of a care plan.
- Outline the process of putting a structured plan in place to better manage their chronic conditions.
- Decide to develop a General Practitioner Management Plan (GPMP,) Medicare Benefits Schedule (MBS) items 229 or 721 and Team Care Arrangements (TCAs), items 230 or 723, to manage your patient’s care needs.
- Collaborate with and coordinate treatment by a multidisciplinary team of health and care providers.
- Tell your patient you’ll start developing the plan.
- Discuss it further with them when they come back in a few days for wound review.
- Ask if your patient minds if an Aboriginal and Torres Strait Islander health practitioner assists you.
- Explain to your patient what is involved.
Your patient agrees to the plan.
Follow-up visit
In the next visit, you do all the following:
- Go through the draft plan and discuss your goals and actions for your patient and the health care team.
- Discuss arrangements for services with allied health professionals.
- Make arrangements for specialist services at the local public hospital with a cardiologist, endocrinologist, renal physician and ophthalmologist.
- Offer a copy of the plan to your patient.
- Ask if you can distribute relevant information from the plan to other health and care professionals.
- Explain that you can refer your patient for some Medicare-subsidised allied health services.
Your patient agrees with your decisions.
Referrals
You decide to refer your patient for allied health services, including all the following:
- 3 individual services with a podiatrist - item 10962.
- 2 individual services with an Aboriginal Health Worker - item 10950.
- one assessment for suitability for group education services with a diabetes educator - item 81100.
Monitoring and support services
As well as these services, you ask your patient to attend services with the Aboriginal and Torres Strait Islander health practitioner. This will be under item 10997, 93201 or 93203.
You do all of the following:
- Check on your patient’s clinical progress.
- Monitor medication compliance.
- Provide self-management advice.
- Collect information to support future reviews of care plans.