Team Care Agreement

The results were emergencies that led to hospitalization – emergency hospitalization (EH) and potentially preventable hospitalization (PPH). These were used to present unplanned hospitalizations or hospitalizations that could have been prevented by proactive management of chronic diseases. HPPs are defined as hospital admissions that could have been avoided by providing appropriate non-hospital health services in accordance with the PPH indicator in Australia`s 2012 National Healthcare Agreement [19]. This indicator consisted of authorizations for 21 diseases, classified overall as «chronic,» «acute» and «inviting to vaccination.» Conditions defined as «chronic» included the main diagnosis: asthma, heart failure, diabetes complications, chronic obstructive pulmonary disease, angina, iron deficiency, hypertension, nutritional deficiencies, rheumatic heart disease. People defined as «acute» included a primary diagnosis: dehydration and gastroenteritis, pyelonephritis, perforated/bleeding ulcer, cellulite, inflammatory pelvic diseases, ear, nose and throat infections, dental diseases, appendicitis with generalized peritonitis, spasms and epilepsy, as well as lymph nodes. Conditions defined as «inviting to vaccination» included influenza and pneumonia, as well as other conditions that can be avoided by vaccination. These PPHs are very similar to the ambulatory care conditions defined in the National Health Service Outcomes Framework [20]. In July 2005, in response to family physician concerns, the Australian government divided the care program into two parts. GP management plans (GPPs) could be implemented by family physicians alone, and the Care Arrangements (TCAs) team was set up to cover cases in which the family physician had to involve other health care providers.4 Ensure that primary and community services are well placed to provide such care and has required changes in the way these services are provided, particularly in the event of changes in episodic supply [7]. In order to identify and facilitate the effort that GPs require to plan ongoing care and coordinate a care team, The Enhanced Primary Care package was introduced in 1999 in the Medicare Benefits Schedule (MBS), with specific item numbers for family physicians, to implement care planning and coordinate team care plans for patients with chronic or terminal illness [8]. This program became the Chronic Disease Management Program (CDM) in 2005 and additional points were added to support the inclusion of services provided by private health care providers (2004) and nurses (2007) [9, 10]. The coordination of treatment for chronically ill patients is already taking place as part of the existing transfer process – family physicians send a patient with a letter of recommendation to specialists or other health care providers awaiting the specialist`s response.

Government of New South Wales. An integrated framework for monitoring and evaluating the care strategy. 2016. www.health.nsw.gov.au/wohp/Documents/ic-monitoring-framework.pdf. Access 1 Apr 2018. More importantly, while care plans have been put in place to encourage GPs to move from an episodic to a holistic approach, they do not necessarily do so. Over the next five years, participants who used PMPs and/or SAD in basic services had higher rates of hospitalization (EHs or PPHs). However, as a result of control over confused factors such as socio-demographic needs, health risk, health status and health care utilization, there was no significant difference between the use of a PMMP or DCA during the basic service period and the first EH and/or PPH over the next five years.