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EPC Chronic Disease Management

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Medicare - MBS Primary Care Item No's
The Medicare Benefits Schedule (MBS) primary care items support primary care services including: general attendances, after-hours attendances, health assessments, nurse practitioners, midwives and chronic disease management.
Some of these services provide particular target groups with preventative health care or improve coordination of multidisciplinary care for people with chronic (or terminal) conditions and complex care needs.
The items include support for services which may be provided by Primary Health Nurses, Aboriginal health workers, Aboriginal and Torres Strait islander health practitioners and other allied health professionals.


Health Assessments -Clarification of Primary Health Nurse involvement
Medicare Health Assessments: MBS Items 701-707 and 715
This fact sheet provides information on Medicare Health Assessments using Medicare items 701 to 707 (the general, time-tiered health assessment items) and 715 (the Aboriginal and Torres Strait Islander Health Assessment)

Primary Health Nurses and Aboriginal and Torres Strait Islander health practitioners may assist GPs in performing a health assessment, in accordance with accepted medical practice and under the supervision of the GP. This may include activities associated with:

* information collection, including gathering of patient information for the medical practitioner and the taking and recording of routine measurements; and
* providing patients with information about recommended interventions at the direction of the GP.

All other components of the health assessment must include personal attendance by the GP.

The time needed to undertake the aspects above of the health assessment by the Primary Health Nurse or Aboriginal and Torres Strait Islander health practitioner may be added to the time taken by the GP to complete the assessment.


Falls Assessment Your patient may be at risk of falls if they:
- have a history of falls
- take 5 or more different medications per day
- take any psychotrophic medications, especially long acting benzodiazepines
- have Parkinson's disease
- have restricted or deteriorating mobility
- have poor or deteriorating visual acuity
- suffer from depression or dementia
- request home visits when they previously came to the surgery
- bring another person to the consultation for physical support
- use an un-prescribed walking aid

The Walky-Talky Test  accompany the patient from one room to another and start a conversation. If the patient needs to stop walking to talk, they could be inherently more unstable and more prone to falling than the patient who can walk and talk simultaneously.

Requirements on the Day Of Health Assessment
A spare room for consultation with the nurse
Urinalysis dipsticks
Disposable gloves
Diagnostic equipment ie Height, weight measures, BP, PO2, etc

Finalising the Health Assessment
The GP is not required to see the patient on the same day as the nurse does the assessment.
Health Assessments may be reviewed annually, therefore it is important to have in place a recall/reminder register for patients who have undertaken an assessment.



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