Chronic Disease Management / Enhanced Primary Care

Project Officer
Kerstin Walther
Phone: 8752 4904

The Enhanced Primary Care (EPC) initiative offers a framework for GPs to provide more preventive care forolder Australians and supports the coordination of multidisciplinary care for patients with achronic condition and complex careneeds.

The components of EPC include:

• Health Check for patients 45-49 year old information and form , waiting room poster , RACGP checklist
• Health Assessment for patients 75+ information and form , Home Safety Checklist , Carer Strain Index
• Health Assessment for patients with an intellectual disability information and form
• Health Check with intellectual Disabilities: Health Care in People with Intellectual Disabilities , Guidelines
• Health Checks for Aboriginal and Torres Strait Islander patients:
  Children aged 0-15 information and form
  Adults aged 16-54 information and form
  Older patients aged above 55 information and form
• Case Conferences information and form
• Healthy Kids Check: Information , Form , Get set 4 Life Brochure , Lea Children Chart
• Type 2 Diabetes Risk Evaluation: information , Risk Assessment Tool (AUSDRISK Tool)

The following risk factors and conditions are currentlynot eligible on their ownfor the purpose of putting together a GP Management Plan or Team Care Arrangement: Obesity, Alcohol or substance abuse, smoking, unspecific chronic pain, hypertension, hypercholesterolaemia, impaired fasting glucose tolerance, impaired glucose tolerance, pregnancy.

• GP Management Plan information and form review
• Example GP Management Plans Diabetes , Asthma , Coronary Heart Disease , Osteoarthritis
• Team Care Arrangement information and form review
• Example Team Care Arrangements on Diabetes , Asthma , Coronary Heart Disease , Osteoarthritis

EPC referrals
• Allied Health Services information and referral form
• Type 2 Diabetes group services information and referral form
• Dental Services: Information , Form - Patient Fact Sheet
• Life Style Modification Programs (LMP) (710, 713, 717): information, Referral form

Links to Allied Health Professional directories

Templates for Medical Director 2 and 3 and Best Practice can be downloaded from our website (please right click below).

Medical Director 2	Medical Director 3	Best Practice
GPMP 45-49 Health check CDM Health Assessment ATSI 0-3 Health Assessment ATSI 3-6 Health Assessment ATSI 6-10 Health Assessment ATSI 10-14 Health Assessment ATSI 55+ Health Check ATSI Adults Health Check ATSI 0-15 Allied Health referral TCA Asthma TCA form TCA Osteoarthritis TCA Review GPMP Asthma GPMP Coronary HD GPMP Diabetes GPMP Osteoarthritis GPMP Review Health Assessment 75+ Health Assessment Disability TCA Coronary HD TCA Diabetes Healthy Kids Check Referral to Lifestyle Modification Program under Prevention of type 2 Diabetes	GPMP Asthma GPMP Coronary HD TCA Asthma TCA Coronary HD TCA Diabetes TCA Osteoarthritis GPMP Diabetes GPMP Osteoarthritis Healthy Kids Check Referral to Lifestyle Modification Program under Prevention of type 2 Diabetes	45-49 Health Check Aboriginal Health Assessment Disability Health Check GPMP Diabetes Referral Diabetes Healthy Kids Check Referral to Lifestyle Modification Program under Prevention of type 2 Diabetes

 

Also available at CSGPN:

• Hard copy resource folder
• Phone support if you have any questions in regard to the item numbers
• Practice visits to provide one-to-one support also to your practice staff
• Resources and advice on Recall and Reminder Systems

For further resources on Asthma and Diabetes management please visit CSGPN web pages.

Useful Downloads:
Lifescripts Resources
SNAP guidelines
Guidelines for Preventive Activities in General Practice (RACGP Red Book)
Putting Prevention into Practice (RACGP green book)

Useful Links:
Inner West local Services
RACGP
Department of Health and Ageing (EPC site)
Department of Health and Ageing, Disability and Home Care
Drs reference site EPC
People with Disability Australia
Aboriginal Health and Medical Research Council
Australian Indigenous
Lifescripts resources library

If you have any questions or comments regarding this website please contact me on kwalther@csgpn.com.au