Orientating Nurses to General Practice - General Practice Queensland

The Practice Nurse role may include:• Identifying eligible patients who would benefit from a caseconference• Understanding and promoting the process of a case conference• Assisting with the organisation and facilitation of the case conference• Assisting in the implementation of the short term management plan֠TIPFamiliarise yourself with the MBS requirements for Case Conferences byreading the explanatory notes in the MBS Schedule to be confident in theprocesses.CHRONIC DISEASE MANAGEMENT ITEMS:(GP Management Plans and Team Care Arrangements)GP Management Plans (GPMP)GP Management Plans are written comprehensive plans for the care of anindividual patient of any age, with a chronic or terminal condition. Therecommended frequency is once every two years, supported by regularreview services. The Practice Nurse can assist in preparing or reviewing aGPMP on behalf of the GP. The GP must review and confirm assessmentsconducted by the Nurse and must see the patient as part of the service.The Practice Nurse role may include:• Identifying eligible patients who would benefit from a GPManagement Plan• Assessing the patient• Agreeing management goals for the patient• Identifying actions to be taken by the patient• Identifying treatment and ongoing services to be providedand make arrangements for these servicesTeam Care Arrangements (TCA)Team Care Arrangements is team assisted care planning for patients with achronic or terminal condition AND who require ongoing care from amultidisciplinary team of at least two other care or service providers. Therecommended frequency is once every two years, supported by regularreview services.23