Enhanced Primary Care (EPC) Medicare Benefits Schedule (MBS) Items

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EVALUATION of the

Enhanced Primary Care (EPC) Medicare Benefits Schedule (MBS) Items and the General Practice Education, Support and Community Linkages Program (GPESCL)

FINAL REPORT July 2003

Professor David Wilkinson, Ms Kathy Mott, Dr Sue Morey, Professor Justin Beilby, Dr Kay Price, Dr John Best, Ms Heather McElroy, Ms Sue Pluck, Ms Vanessa Eley

EVALUATION of the Enhanced Primary Care (EPC) Medicare Benefits Schedule (MBS) Items and the General Practice Education, Support and Community Linkages Program (GPESCL)

FINAL REPORT July 2003 Professor David Wilkinson, Ms Kathy Mott, Dr Sue Morey, Professor Justin Beilby, Dr Kay Price, Dr John Best, Ms Heather McElroy, Ms Sue Pluck, Ms Vanessa Eley

© Commonwealth of Australia 2003 ISBN: 0642 82244 1 This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from the Commonwealth available from the Department of Communications, Information Technology and the Arts. Requests and inquiries concerning reproduction and rights should be addressed to the Manager, Copyright Services, Info Access, GPO Box 1920, Canberra ACT 2601.

PUBLICATION APPROVAL NUMBER: 3242 (JN7523)

Table of Contents ACKNOWLEDGEMENTS ................................................................................................ IV THE CONSORTIUM AND PROJECT TEAM ................................................................... IV EXECUTIVE SUMMARY....................................................................................................1 BACKGROUND ....................................................................................................................1 RESULTS.............................................................................................................................1 DISCUSSION ........................................................................................................................5 CONCLUSION ......................................................................................................................6 OVERVIEW OF RECOMMENDATIONS.....................................................................................7 INTRODUCTION AND BACKGROUND............................................................................9 THE EVALUATION BRIEF ...............................................................................................12 METHODOLOGY ..............................................................................................................13 ORIGINAL METHODOLOGY ................................................................................................13 AMENDED EVALUATION METHODOLOGY ..........................................................................13 LIMITATIONS OF THE METHODOLOGY ................................................................................16 RESULTS ...........................................................................................................................17 SECTION 1: UPTAKE OF THE EPC MBS ITEMS............................................................18 LEVELS OF UPTAKE...........................................................................................................18 SECTION 2: MAJOR THEMES IDENTIFIED FROM FIELDWORK................................20 DISCUSSION .....................................................................................................................35 PROMOTING AWARENESS, USE AND UPTAKE .....................................................................35 SATISFACTION WITH THE ITEMS.........................................................................................36 PRACTICE AND SYSTEM CHANGE.......................................................................................39 IMPACT ON QUALITY.........................................................................................................39 CONTRIBUTION TO POLICY PRIORITIES ..............................................................................43 CONCLUSION ...................................................................................................................44 REFERENCES ....................................................................................................................45 ACRONYMS AND ABBREVIATIONS .............................................................................46 DIAGRAM 1 : POSSIBLE PATHWAYS FOR MANAGEMENT OF PATIENTS WITH CHRONIC ILLNESSES AND COMPLEX CARE NEEDS… … … … … … … … … … … … ...40 APPENDIX 1: INTERVIEWEES FOR THE EVALUATION OF THE EPC MBS ITEMS AND GPESCL PROGRAM.................................................................................................47

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Acknowledgements v v v v v v v

Commonwealth Department of Health and Ageing staff – Ms Claire Caesar, Ms Alison Duffy, Ms Michelle Roffey EPC Evaluation Steering Committee – Mr Tony Wade, Dr Gerald Segal, Ms Bev Sibthorpe, Mr Martin Mullane, Dr Bronwen Harvey, Dr Jane Cook, Ms Claire Caesar The 23 Divisions of General Practice that took part in the evaluation All practices (GPs, nurses, practice staff), allied health providers and organisations and consumers that took part in the evaluation State Based Organisations and the Australian Divisions of General Practice (ADGP) Ms Michele McHugh for document and literature review contributions Stakeholder organisations that made a submission: • The Pharmacy Guild of Australia • The Speech Pathology Association of Australia Ltd • Australian Physiotherapy Association • Consumers’Health Forum • Royal Australian College of General Practitioners • Illawarra Division of General Practice • Fremantle Regional Division of General Practice • Rockingham Kwinana Division of General Practice • Canning Division of General Practice • Adelaide North East Division of General Practice • Ipswich and West Moreton Division of General Practice • Canterbury Division of General Practice • Four Divisions of General Practice which did not wish to be identified.

The Consortium and Project Team The Consortium brings together people with a diverse range of backgrounds and perspectives. Between them the consortium embraces academia, clinical practice, research, policy and management from both the public and private sectors. There is a strong understanding of general practice and allied health practice amongst the team members. Both provider and consumer perspectives exist in the team. Professor David Wilkinson

Pro Vice Chancellor and Vice President, Division of Health Sciences, University of South Australia (Project Director) Professor Justin Beilby Head, Department of General Practice, Adelaide University Dr Sue Morey AM Director, Morey Australia Pty Ltd Dr John Best AM Director, Diagnosis Pty Ltd Dr Kay Price Assistant Director, Centre for Research into Nursing and Health Care, University of South Australia Ms Kathy Mott Director, KM Consulting Services Pty Ltd (Project Manager) Ms Heather McElroy Statistician, Department of General Practice, Adelaide University Ms Sue Pluck, Ms Vanessa Eley Research Assistants, KM Consulting Services

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Executive Summary Background The Enhanced Primary Care Medicare Benefits Schedule (EPC MBS) items became available in November 1999 as part of the broader Enhanced Primary Care Package announced in the 1999/2000 Commonwealth Government Budget. The Government also made $8.1 million available for a General Practice Education, Support and Community Linkages (GPESCL) Program to educate GPs, allied health providers and the community about the items and to promote their use. The Commonwealth Department of Health and Ageing (DoHA) commissioned an evaluation to “describe, assess and make recommendations for improvement on the education and awarenessraising about the new items, consumer and provider satisfaction, impact on practice, systems and quality and their contribution to primary health care policy development and implementation”. This evaluation of the EPC MBS items and GPESCL Program was conducted throughout late 2001 and all of 2002. Both quantitative and qualitative data were collected, comprising: • an extensive document review (quarterly and final GPESCL Program reports from State Based Organisations of Divisions of General Practice (SBOs) and any other reports of projects related to the GPESCL Program or the EPC MBS items’implementation) and a limited review of literature about health assessments for older people; • interviews with Australian Divisions of General Practice (ADGP) and the State Based Organisations (SBOs) (n=9) and key stakeholders (medical, allied health and consumer organisations) (n=58); • detailed analysis of data on uptake of the EPC MBS items over the period from 1 November 1999 until 31 October 2001 and some additional analysis on data to 31 July 2002; • examination of monthly fluctuations in care plan claims particularly around May 2002 using the most recently available data from the HIC website (for claims processed by 31 November 2002); • invited submissions from key general practice, allied health and consumer stakeholders; • case studies of 39 general practices from all States and Territories; • telephone and face to face interviews with 23 Divisions of General Practice (within which EPC MBS item uptake had been especially high or low); • consumer telephone interviews (n=67); and • face to face and telephone interviews with allied health providers (n=38). All interviews were analysed for themes, repetition, areas of disagreement and divergence within each category of stakeholders and then a critical analysis performed across stakeholders and data sources.

Results Awareness, Understanding and Use of the EPC MBS Items Most GPs had used the items, but uptake was highly variable During the first two years, almost three quarters (74.4% or 11,388) of GPs in Australia claimed at least one EPC MBS item. By October 2001, 5,000 GPs were claiming for at least one EPC MBS item each month. Male GPs claimed 80% of the items. Those who claimed tended to be younger than the general profile of GPs in Australia. Ten percent of GPs were responsible for 50% of the health assessments claimed and 10% claimed 80% of all care plans, with 5% having claimed more than 100 1

care plans each. Approximately ten percent of GPs (1,591) had rendered only one service using the EPC MBS items. Health assessments were the most used items, case conferences the least; care plans increased over the GPESCL Program period but there was confusion about their use Health assessments were well used early in the two-year period of implementation with the number of claims reaching 15,000 per month by October 2001. Eighteen percent of the population 75 years and over had a health assessment in the first two years of the items being available. Of those who had a health assessment before 31 July 2001, 45% had a second health assessment by 31 July 2002. Numbers of health assessments conducted in the home came to equal those done in the surgery. Rural uptake of health assessments was 36% higher than urban uptake per Full Time Equivalent (FTE) GP. Those interviewed believed health assessments were acceptable, practical and appropriately remunerated. Only half of the GPs claiming EPC items claimed care plans, and only one-quarter claimed case conferences. GPs claimed a care planning EPC MBS item for 109,778 people during the first two years of availability. A decrease in care plans since May 2002 was primarily due to a substantial reduction in the number of community care plans being prepared. The decrease in care plans stabilised in July 2002. The decrease could possibly be attributed to one or all three of the following factors, the clarification of the care plan in the Explanatory Notes of the May 2002 Supplement to the Medicare Benefits Schedule, the progressive introduction of the new disease specific MBS items and the cessation of the care planning component of the Practice Incentives Program (PIP). Care planning was widely used among the case study practices and, while considered useful for some patients, there was confusion over the requirements for the involvement of other providers and therefore inconsistent implementation and some concern about the level of remuneration. Case conferencing was not extensively used, considered too complex, time consuming and poorly remunerated for the effort involved, but was seen as useful by some GPs for a very small number of highly complex patients. Allied health providers had major concerns about their limited role in care planning, and about lack of resources and remuneration. Time availability and workload were major issues for GP and allied health utilisation of the items. GP involvement in, and initiation of, care planning and case conferencing in residential aged care facilities was limited but considered to be useful by those who used the items for this purpose. Case conferences claimed reached 8-900/month by late 2001. Case conferences for residents in aged care facilities accounted for 20% of all case conferences, discharge case conferences accounted for 6%. 92 percent of GPs claimed fewer than 10 case conferences in total. Less than one in ten (6.9%) of all people who received a service through use of an EPC MBS item had both a health assessment and a care plan. GP awareness was high, but allied health providers and consumers had little education and awareness of the items Face-to-face, practice based peer education and support was considered the most effective mechanism for promoting awareness and uptake of the new EPC MBS items amongst GPs. GP awareness of the items was high, but there was poor awareness amongst allied health providers and consumers. Most GPs were exposed to some form of education, information or support throughout the GPESCL Program period. Those interviewed in practices were familiar with the full range of items available even if they were not using them. Consumers interviewed were largely unaware of the items

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until approached by their GP with an offer of a health assessment or care plan. GPs and Divisions reported there was very limited demand from allied health workers for GPs to participate in the care planning and case conferencing of other agencies. There was almost no demand from older people for health assessments and no demand from people with chronic illness for care plans. GPs saw the lack of awareness by consumers and allied health providersas a barrier to using the items. Satisfaction Satisfaction with health assessments was high amongst consumers and GPs Satisfaction was highest for health assessments. Positive comments GPs and practice staff made about the health assessments included patient and carer satisfaction, reinforcement of clinical management, identification of previously hidden issues, improved relationship with the patient, a comprehensive health record for the patient and GP, and the preventive nature of the exercise. Feedback from consumers about health assessments was generally positive with most consumers reporting increased confidence in their GP (86%), and in what they need to do about their health problems (89%). Many believed they had learnt something from the process (68%) and had gained a better understanding of their conditions (74%). Two thirds believed they had received more help with their problems (66%) and had a better quality of life (64%) since the service was delivered. GPs found care plans complex, but useful for some patients Satisfaction with care plans was mixed, with most GPs being unsatisfied. The main criticisms of the care plan item by GPs, Divisions and stakeholders were the complexity of the requirements, the amount of paperwork involved and the time needed to review medical notes and test results to achieve a quality care plan. Almost all GPs interviewed took on the entire care planning process themselves, with the impact on their own time being substantial, given that most would do the paperwork and background at night or on their days off. Positive comments about care plans included that they: • provided a complete and up to date history; • ensured that patients’issues were listened to and needs met appropriately instead of in an ad hoc manner; • encouraged a comprehensive approach to needs; • influenced the way GPs approach their patients with chronic conditions; • increased patient involvement; • had the capacity to reduce hospital admissions for preventable events; • created the opportunity to engage with other health providers; and • were a useful training tool for Registrars. Consumers were generally satisfied with the care plans, with comments that the plan helped them feel they had control over their own health, kept other providers / specialists informed and was reassuring. GP satisfaction with care plans would improve if GPs were explicitly allowed to delegate appropriate tasks to another party, as they can with the information collection component of a health assessment. It would be preferable to allow a nurse, with appropriate community experience and skills, to undertake parts of the care plan process, but still requiring the GP to conduct the clinical aspects of the care plan. There is a need to recognise the value of the GP and patient discussing a patient’s health issues and needs and developing a plan for treatment and services. An MBS item could be created to reward this activity, leaving the existing care planning items for a small number of high need, very complex patients who require intensive work by a number of different providers. The new MBS item could be for the development of a disease management plan.

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Case conferences were difficult to organise, but useful for some patients In relation to case conferencing, both allied health and GPs noted that the logistics of getting three or more people to meet or speak at the same time were very difficult and would mitigate against them being possible for any more than a small number of patients with highly complex care needs. GPs who did use them found the item to be very useful for patients with particular issues including drug dependence, mental illness, children with ADHD, palliative care, chronic pain, osteoporosis, housebound elderly patients or for adolescent mental health problems. The residential aged care facility staff interviewed indicated that the involvement of GPs in their care planning and case conferencing activities would increase over time as the sector gained better understanding and experience. Impact on Practice and System Important role of practice staff and practice systems was not optimal Almost all GPs interviewed had begun their use of EPC items by trying the health assessment items, and most GPs were keen to do health assessments for all of their patients 75 years and over. Almost two thirds of practices visited used the services of a practice nurse to undertake the information collection component of health assessments. They believed that the practice nurse was critical to the successful implementation and integration of health assessments or care planning into practices. The majority of GPs and practice staff felt that the in-home assessment was the best and most effective, however those who did surgery-based assessment felt they were still quite useful in identifying needs and issues. Important role for allied health providers was not fully tapped The submissions reported that GPs generally had a limited understanding of the roles of providers in the rest of the health care team and that allied health providers did not understand the requirements of the items on GPs. Several organisations believed that there was a great deal still to be done to enable collaboration between GPs and allied health providers at the local level, but that systems were now being developed. Key system barriers to uptake of the items existed All stakeholders named demand for acute and episodic care as being a major barrier to GP uptake of the items. SBOs and Divisions of General Practice (Divisions), allied health providers and GPs all acknowledged that historical and current models of practice were constraining the ability of general practice to better integrate with the rest of the health care system. Consumer organisations felt that having a health system provided by national, state, territory and local government as well as by private providers made for a “serious lack of coordination”. Substantial barriers to GP involvement in residential aged care facilities and discharge planning existed despite the availability of the EPC MBS items. Some practice and system change had commenced Systems within general practice to enable health assessment, care planning and case conferencing were in early development. Most GPs stated that, since the introduction of the EPC MBS items, they had made changes to the way they managed their workload in order to accommodate the items, with over half the case study practices employing extra staff, or extending the hours of existing staff to assist with the additional tasks. Better use of computer systems for recall and reminders and reorganising of workloads and duties were essential for general practice to move from the notion of a reactive GP to a

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comprehensive general practice service offering preventive care and effectively managing their more complex patients with more complex care needs or chronic illness. General Practitioners, Divisions and practice staff agreed that, where general practitioners employed practice nurses to undertake the information collection component of health assessments and/or to assist with care plans, case conferences and discharge planning, the impact on GP workload was minimised, and the relationships with allied health were, to some extent, enhanced. Impacts on Quality of Care Strong support existed for enhancing the capacity of general practice to better respond to the needs of older people and people with chronic illness and complex care needs There was strong support for the notion of enhancing the capacity of general practice to respond better to the needs of older people and those with chronic conditions and complex needs, using the items as a vehicle. However, the current structure and nature of general practice, based on a fee for service model, with physical isolation from other providers, and training and mentoring within a medical model, created challenges for multidisciplinary activity. One third of practices interviewed stated that financial benefit was a motivating factor to use the items, however the likelihood of improved outcomes for patients and the desire to operate in a more ‘preventive health’ or ‘integrated primary care’ based manner were, in 80% of case study practices, stronger motivating factors. Some indication of improved quality of care was apparent Divisions, GPs, practice staff, allied health providers and consumers agreed that the items provided the opportunity for more holistic health care. Many GPs commented on the items as rewarding them for the good practice they have always done without remuneration in the past. Many commented that it was good to have the items available so that they could take the time to gather a comprehensive history and step back and look at the bigger picture with their patients rather than reacting to acute episodes. Extra time provided when a health assessment was done or a care plan was prepared, was named most often as being the aspect consumers valued. GPs also liked the improved relationship with patients and the preventive approach the items engendered. Consumers, allied health providers and GPs all supported the sharing of information amongst those involved in patient care.

Discussion Positive impacts on practice and systems both within practices and between general practices and allied health service providers were observed. Although substantial impact was limited to a small number of practices there do seem to have been important shifts in the fundamental approach of general practitioners towards the care of older patients and those with chronic conditions, and complex care needs. The introduction of the EPC MBS items has sown the seeds of change for general practice and enabled many practitioners to at least explore how to better organise their practices to provide care to some of their patients. It seems likely that with continued development and promotion even more fundamental change can and will occur in Australian general practice. Some common models have emerged: • use of a nurse or allied health provider for health assessments, either based in the practice or contracting an external agency; • delegating administrative, referral and some patient contact tasks for care planning to another practice staff member; • allied health providers made available to practices through employment within Divisions; and 5

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recall and register systems for identifying patients for health assessments and care plans and their reviews.

There are some indications of quality practice. Evaluation of impact on health outcomes was not possible. However there were some positive indications of impact on quality of services provided by GPs and others: • more time being spent with patients and reviewing records; • increased access to some services by some consumers; and • increased consumer and GP confidence. Health assessments and care plans can make a difference. Evidence from randomised trials is that health assessments for the elderly have the potential to promote early identification and intervention, assisting people to stay in their own home and remain healthy longer (Elkan et al 2001). Most consumers interviewed agreed that the health assessment or care plan had made a difference to them, either in relation to their health or quality of life. The EPC MBS items and GPESCL Program have had a substantially positive policy impact. Some of the impacts on primary health care policy priorities of the Commonwealth Government are: • Access to some services has increased for some people. • Rural consumers have not been disadvantaged. • Integration has been facilitated. • The GP role in care co-ordination has been promoted. • Multidisciplinary care has been encouraged. • High and low socio-economic areas appear to have similar access to EPC services. While a positive start has indeed been made, there remains potential for further expansion of uptake of health assessments to the entire eligible population, and to a more focussed use of care plans and case conferences.

Conclusion The EPC MBS items and accompanying GPESCL Program have made a significant contribution to improving the management of patients with chronic illness and complex care needs in general practice Australia. Two to three years post implementation it is clear that, while uptake has been variable across Australia, and while the quality of use is not yet optimal, a fundamental shift has occurred in general practice. There is now a structured approach to multidisciplinary care and the "language" of practice is changing. Patience and persistence will be needed as fundamental change inevitably takes time, but the basics and the current platform are right. Consumers have generally welcomed the initiative of their GP in proactively calling them in to have a comprehensive discussion and assessment of their health and needs. Practice and system changes are emerging. Most GPs are now familiar with health assessments and have plans to continue their use within their practice, with many engaging skilled staff to assist them to manage this new activity within their current workloads. Care planning has been of variable quality, but the appropriate use of the items for a smaller group of patients with multiple chronic conditions and complex care needs is now emerging. There have been some improvements in quality of care through better communication and more comprehensive approaches to information gathering and allied health and community services usage.

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The EPC MBS items have enabled key policy initiatives of the Commonwealth Government to be implemented in relation to access to appropriate care for older people, integration with other health providers, care co-ordination by GPs, multidisciplinary approaches to care, access and equity. The introduction of the EPC items has clearly changed the language of general practice. Thus they are a success and should be continued. There is no doubt some aspects of use of the items can be improved; there are lessons to learn and adjustments to be made. This is to be expected. These are early days in a major change process that has enabled other initiatives such as the chronic disease management incentives to be more easily implemented. In some areas profound change has occurred, in others the right things are being done. Patience and persistence are required to embed this change into everyday practice. Overall the introduction of the EPC MBS items is a good news story that is in the early stages of changing Australian primary health care.

Overview of Recommendations 1.

Future promotion of the EPC Items by the Department, Divisions, professional groups and others should focus on their use within the broader policy framework of care for older Australians, and people with chronic and complex conditions.

2.

GPs should be encouraged to conduct health assessments annually on eligible patients.

3.

The EPC Item Descriptors and Explanatory Notes for health assessments and case conferences should not change in the foreseeable future to ensure some stability. Trends in uptake should continue to be actively monitored.

4.

The Explanatory Notes for the EPC Items in the Medicare Benefits Schedule Book for care plans should be clarified and simplified. The intent should remain the same; however minor changes could be made to more clearly spell out practical expectations.

5.

For care plans, the use of a nurse and / or administrative staff for the technical components of the service should be allowed and encouraged.

6.

A new MBS EPC Item should be created to encourage the development of care plans for patients who have a chronic condition, but for whom multidisciplinary team care is not required. This could be known as a disease management plan.

7.

Further strategies need to be developed to enhance the linkages between general practitioners, allied health professionals and other service providers.

8.

The Department should resource a program of operational research aimed at developing, testing and disseminating models of effective management of patients with chronic conditions and complex care needs.

9.

The Department should ask the General Practice Computing Group (or other relevant body) to advise on how the data collection needs of the EPC services, including coding, can best be integrated with electronic medical records.

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10.

General Practice Education and Training Ltd. should be asked to ensure that GP training consortia curricula and training opportunities include a specific focus on the management of older patients and the multidisciplinary management of those with chronic and complex conditions.

11.

Any future review of the EPC MBS items should encompass their linkages with the more recently introduced chronic disease items, and the other key policy frameworks for older people and those with chronic illness.

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Introduction and Background The Enhanced Primary Care Medicare Benefits Schedule (EPC MBS) items and the General Practice Education, Support and Community Linkages (GPESCL) Program were part of the Enhanced Primary Care Package announced in the 1998/99 Commonwealth Government Budget. Their intent had been previously outlined in a letter from the Prime Minister to Senator Harradine, tabled in the House of Representatives on 10 December 1998. The aims of the EPC Package, as expressed in the letter from the Prime Minister, were, “… to advance substantially the quality of care of the aged”, in the context of the International Year of the Older Person. At the same time the Prime Minister, in his letter, noted that he and the Senator “… (had) talked of the provision of a co-ordinated care plan for disadvantaged elderly people”. The Prime Minister further noted that “this would be a very substantial change in our health care system and the Government is prepared to trial it seriously”. The Prime Minister then described the basis of a co-ordinated care trial, and the fact that the Government was prepared to provide “in the order of $25m” for such trials to address the health care needs of older people who were chronically ill or disadvantaged. To implement the program outlined by the Prime Minister, the EPC Package introduced in the Budget included seven initiatives: • EPC MBS items: rebates for voluntary annual older age health assessments, and for care planning and case conferencing; • General Practice Education Support and Community Linkages: to provide professional education and support for improving local level linkages between GPs and other medical and non-medical providers; • Commonwealth Carelink Centres: to provide easier access for people to information about available care; • Coordinated Care Trials: further trials of approaches to improving coordination of care for people with chronic conditions and multidisciplinary care needs; • Sharing Health Care: programs to encourage the use of chronic disease self-management strategies by people with chronic conditions; • Falls Prevention in Older People: improved prevention of falls among older Australians in community, residential and acute care settings; and • Integration of Health Information Systems: further research and development of information technology to support improved care through the exchange of data between health care providers. These initiatives aimed to promote a more integrated approach to service delivery among health professionals and other service providers, and a greater role for consumers in decision-making about their health (Department of Health and Aged Care 2001; Royal Australian College of General Practitioners 2000a).

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The EPC MBS items introduced in November 1999 were: • Health assessments for non-Indigenous people 75 years of age and over, and for Indigenous people 55 years and over - An in-depth assessment of the health of older patients in the context of their social and physical well-being, either in the home or at the surgery, able to be conducted every year. •

Multidisciplinary care planning for people of any age with chronic conditions and multidisciplinary care needs living in the community (community care plan) or in hospital (discharge care plan) - To provide an opportunity for the GP, in consultation with at least two other health professionals or service providers, to prepare, review, or contribute to, a comprehensive and longitudinal plan for the care of an individual patient with chronic or terminal conditions and multidisciplinary care needs. To enable GPs to shift from short-term, episodic fragmented care to whole person care that is integrated with other health care providers.

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Case conferencing for people of any age living in the community (community case conference) or in a hospital (discharge case conference) - To provide an opportunity for the GP to organize, or participate in, a conference with two or more other health professionals or service providers, in order to identify and discuss the care goals of a patient with a chronic or terminal condition and multidisciplinary care needs. To enable GPs to shift from short-term, episodic fragmented care to whole person care that is integrated with other health care providers. (Royal Australian College of General Practitioners 2000b).

In November 2000, a further set of items was introduced for contribution to care planning and organising or participating in case conferencing in relation to residential aged care facility residents. The new items represented a departure from previous listings on the MBS in that the items allowed for GPs to be paid for non-patient contact time and for preventive activities within the existing fee-forservice system. GPESCL was a Department of Health and Ageing (DoHA) funded program to promote the use of the EPC MBS items through education, support and community linkages activities involving GPs, other health providers and consumers. The program included a number of elements: • funding to the ADGP for national coordination of Divisionally-based EPC training and support activities; • funding to each of the SBOs to enable them to assist Divisions to train and support GPs in using the EPC MBS items; • funding to the Royal Australian College of General Practitioners (RACGP) to develop Standards and Guidelines for use of the EPC MBS items; and • funding to the RACGP to develop a Clinical Audit Package for the EPC MBS items. As part of the GPESCL Program, the Department of Health and Ageing also funded a number of national workshops, to provide training and information to the Divisions Network or to address specific issues eg Indigenous issues; allied health professional issues; and linkages with primary mental health. The Council of the Ageing (CoTA) was funded to develop and evaluate a peer education program to inform older people about health assessments. In late 2000, the Department of Health and Ageing sought tenders from interested consultants for an evaluation of the EPC MBS items and the GPESCL Program. The Consortium led by the University of South Australia was awarded the tender in mid 2001. The multi-method evaluation was done during late 10

2001 and throughout 2002. The Population Health Section of the General Practice Branch of the Department of Health and Ageing had oversight of the evaluation, with advice from the EPC Evaluation Steering Committee.

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The Evaluation Brief The evaluation brief from the Department of Health and Ageing was for the consultants to describe, assess and provide recommendations for improvement on: • strategies to promote awareness, use and uptake of the EPC MBS items; • consumer and provider satisfaction with the items; • impact of the items on changes in practice and changes to systems of health care delivery; • impact of the items on the quality of health care; and • contribution of the EPC MBS items and the GPESCL Program on primary health care policy development and implementation. The aim of the evaluation was to assist the Department of Health and Ageing to determine the impact of the strategies to promote and support use of the items, the impact of the items themselves and any health or policy outcomes that could be attributed to these initiatives. Models for delivery of care were to be identified and a comprehensive overview of the implementation of the items into practice was to be documented. Future directions for the items in particular were to be explored.

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Methodology Original Methodology The original methodology proposed for the evaluation was a blend of qualitative and quantitative methods, including a national survey of GPs (10% sample N=2,300), survey of Divisions of General Practice (N=123), case studies (N=6), focus groups of GPs, allied health providers and aged care facility staff in each of the case study Divisions and analysis of EPC item uptake data. We started with an 8-week Scoping Study that aimed to define the key issues in the implementation of the GPESCL Program and the EPC MBS items, to ensure the evaluation would be appropriately structured for assessing strategies and implementation.

Amended Evaluation Methodology The Scoping Study indicated the need to change the original methodology and this was supported by the EPC Evaluation Steering Committee and the Department. It was agreed to cancel the planned national survey and to increase the number of case studies. Much of the information that would have been sought via survey from GPs and Divisions was considered already available and the case study method was felt to be more informative as to the practical issues in the use of the items. Face to face, on-site interviews also enable the researcher to gain an understanding of the environment and broader attitudinal approaches of the practitioners concerned. Models for use of the items could also be explored from a variety of perspectives and specific information sought to build a clearer picture of the models and their transferability to other practices. The amended methodology employed within the evaluation remained a blend of qualitative and quantitative methods: • document review (quarterly and final GPESCL Program reports from SBOs and any other reports of projects related to the GPESCL Program or the EPC MBS items implementation) and review of literature about health assessments for older people; • interviews with SBOs and National Stakeholders; • case studies of practices using the EPC MBS items; • patient telephone interviews; • interviews with allied health providers; • data analysis of uptake of the EPC MBS items; • submissions invited from stakeholders; • Rapid Appraisal Technique for the Scoping Study; and • Thematic and Critical Analysis techniques for the results of the Implementation Stage. Data gathered through each method was analysed for themes, repetition, agreements and dissenting views. It was then reanalysed to bring the information from each method into a coherent whole. Project team members who had generally not gathered any, or had only gathered some, of the data conducted initial analysis of the data manually. The original interpretation was checked by a second person who was involved in the data collection initially to ensure the overall interpretation matched their understanding of the raw data. An overall analysis was conducted by three people from the team. The three team members conducted a thematic analysis and discussed their key conclusions from this analysis. Together they agreed on 13

the conclusions to be included in the final report. The consortium met to discuss this set of conclusions and draft recommendations for the report. These were circulated and edited on three occasions before acceptance for the report. Therefore, analysis of the data gathered during the evaluation enabled the consortium to base their conclusions and recommendations on reliable evidence, based on the broad range of experiences and views of large numbers of practitioners and consumers. Document Review The Department provided documents from ADGP and the SBOs about their GPESCL activities. We also collected a significant amount of documentation, reports and studies from various stakeholders, SBOs, Divisions, and academics associated with the Universities. These reports and documents were initially read for background material as part of the broader document review, which was carried out throughout the evaluation. Published literature about health assessments was sourced through Consortium members and other key stakeholders. Interviews with State and National Stakeholders We interviewed people in a wide range of agencies mainly face to face, but by telephone when essential. Those interviewed were: • officers of State and Territory Health Departments; • officers of the Department of Health and Ageing in Canberra and each State and Territory office; • key personnel of the RACGP and the Australian Medical Association (AMA); • the ADGP; • the Consumers’Health Forum; • the National Association of Community Controlled Health Organisations; • the EPC Task Force – Chair and key members; and • the SBO EPC Co-ordinators. A standard set of questions was developed for use in the Scoping Study with some variations for State/Territory Health Departments. A Thematic Analysis was done to identify the main themes. Case Study Interviews and Selection of Divisions and General Practices for Case Studies Twenty Divisions were selected for the case studies. They were chosen on the basis of their high uptake of health assessments or care planning Items. Three Divisions were selected to inform the evaluation about barriers and issues in areas of low uptake of the items. For each of the 123 Divisions the numbers of health assessments and care plans for the defined geographic area were predicted using HealthWIZ data about the demographics of the Division. The actual numbers of health assessments and care plans were then used to provide a ratio. The Divisions were ranked and those with the highest ratios were identified within each State and Territory. Divisions with both high health assessments and care plan uptake were initially selected, then those with high health assessments only and high uptake of care plans only, then one Division ranked in the mid range of uptake and three Divisions with both low health assessment and care plan uptake. A nominal allocation for each State and Territory was set for the high uptake Divisions to ensure coverage and enable larger numbers of Divisions to be represented in the more populous states.

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Number of Case Studies Divisions of General Practice per State ACT 1

New South Wales 5

Northern Territory 1

Queensland 4

South Australia 2

Tasmania

Victoria

1

4

Western Australia 2

A total of 39 case study practices were selected across the 20 high uptake Divisions. The case study practices, were chosen to provide a range of practice sizes and uptake profiles. The case studies comprised interviews with practice staff, including GPs, practice managers, and nurses, depending on the staff structure of the practice and the wishes of the principals of the practice. Most interviews were conducted face-to-face using a common format. The interviews covered the five key evaluation questions. Three low uptake Divisions were selected from the national ranking of Divisions. Interviews were conducted with the SBO in the State where the Division is located and with the Division itself. The analysis looked for common issues and explanations for low uptake across the interviews. Patient Interviews Case-study practices were asked to identify 6-8 patients who had received a health assessment or a care plan over the past 3-6 months. The practice was provided with a letter, Information Sheet, Consent Form, and reply paid envelopes to mail out to the identified patients. No patient details were provided to the evaluators until consent was received either by the practice or directly to the evaluation team office. An interview proforma was devised. All interviews took place by telephone. Consumers were contacted up to three times to arrange an interview time, after which they were deemed unreachable. The interview results were clustered by question and analysed for themes, frequencies of ratings, repetition, agreements and dissenting views. Allied Health Provider Interviews Fieldwork team members sought assistance from GPs and practice staff in the case study practices in identifying appropriate allied health services. The allied health services were contacted and sent background information. Most of these interviews were conducted by telephone. The results were analysed for themes, agreements and dissenting views. Analysis of EPC Item Uptake Under the provisions of graph 130(3)(a) of the Health Insurance Act, the General Practice Branch of the Department of Health and Ageing provided de-identified unit record data relating to EPC services rendered between 1 November 1999 and 31 October 2001, and claimed through the Health Insurance Commission (HIC) prior to 31 December 2001. The majority of results reported have been based on this initial data. A subsequent dataset was provided with EPC services rendered between 1 November 2001 and 31 July 2002, and claimed through the HIC prior to 30 September 2002. The data did not include claims made through the Department of Veteran’s Affairs. EPC services included item numbers in the November 2000 Medicare Benefit Schedule (MBS) groups A14 Health assessments (items 700 to 706), and A15 Multidisciplinary Care Plans and Case Conferences (items 720 to 815). Items relating to case conferencing services by consultant physicians (items 800 to 815), introduced in November 2000, were excluded from the analysis. 15

Submissions Key national stakeholders representing general practice, allied health providers and consumers (n=17) and the non-case study Divisions (n=100) were written to, inviting them to submit comments to the evaluation, addressing the five evaluation objectives. Submissions received were read and summarised for themes and key issues.

Limitations of the Methodology This mixed-methods action research has specific strengths. The data on use of the items is comprehensive; there was high participation in the interviews by a wide range of stakeholders across all interests at national, State and local levels. The qualitative case study approach complements the quantitative data effectively by enabling models of service delivery to be explored and the real experience of all those involved in the delivery of services using the EPC MBS items to be documented. However, the 39 practices are a small proportion of the approximately 6,000 practices in Australia. We cannot extrapolate the findings to the entire general practice workforce. Involvement as a case study practice was voluntary. It is suggested that the practices participating were more likely to be those with links to the Divisions, approachable or ‘doing the right thing’. Therefore, the study serves to inform, illuminate and challenge rather than to be representative.

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Results Results are presented in two main sections. First, we report analysis of the quantitative data available from the HIC on uptake of the EPC MBS items for the first two years of their availability since November 1999. This is supplemented by a brief analysis of available data on further trends in item uptake more recently. The second section reports the findings from our fieldwork. The analysis of these qualitative data is presented as a synthesis of major themes that emerged from across all data sources including GP interviews, practice visits, interviews of consumers and allied health professionals, and extensive document reviews. It is important to recognise that in reporting these broad themes we cannot give numbers and percentages unless the information was specifically gathered or analysed in that way.

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SECTION 1: Uptake of the EPC MBS Items Levels of Uptake Almost three quarters (74.4% or 11,388) of GPs in Australia had claimed at least one EPC MBS item in the first two years of the program. By October 2001, 5,000 GPs were claiming for at least one EPC MBS item each month (between 25 and 30% of all GPs). Of those GPs who had claimed an EPC MBS item, 85% had claimed health assessments, 50% had claimed care plans and 26% had claimed case conferences. Rural uptake of health assessments was 36% higher than urban uptake per FTE GP. GPs that had claimed EPC MBS items tended to be younger than those who had not claimed. Male GPs claimed 80% of items. More extensive analysis of these data has been published in the Australian Health Review (Wilkinson et al 2002a, 2002b, 2002c, 2002d, 2002e, 2002f). Further analyses of urban-rural differentials, association with socio-economic inequality, and practicelevel factors have been submitted for publication in peer-reviewed journals. In brief, 5.5% of people aged 65 or older live in moderately accessible or more remote ARIA (source: HealthWIZ, Australian Census 1996) and 5.2% of EPC services were rendered in these areas. People from lower socioeconomic areas appear to have had at least equal access to EPC services with 26.3% of EPC services occurring in regions with the highest 25% of socio-economic disadvantage (not adjusted for age). Most GPs had used the items, but uptake was highly variable A small number of GPs claimed a large number of items in the first two years of the program. Half of all claims were made by only 919 GPs (6% of all GPs). Ten percent of GPs were responsible for 50% of the health assessments claimed and 10% had claimed 80% of all care plans, with 5% having claimed more than 100 care plans each (totalling 45% of all claims). The overlap between the two groups of GPs who claimed most health assessments and those who claimed most care plan items was 430 GPs, which is about 4% of all doctors doing some EPC work (430/11,388). These results demonstrate that GPs tend to favour one or the other and indicate that there are very few who are claiming large numbers of items overall, and few who are claiming across the three groups of items. Health assessment items were used most; case conferences least Health assessments were well used early in the two-year period after implementation, with the number of claims reaching 15,000 per month by October 2001. Eighteen percent of the population 75 years and over had a health assessment during this period1. Of the 161,167 people who had a health assessment before 31 July 2001, 45% (73,264) had a second health assessment before 31 July 2002. Of the people with multiple health assessments, 85% had their second one within eighteen months and 96% within two years. Numbers of health assessments conducted in the home have come to equal those done in the surgery. Slightly less than 1% of all health assessments claimed are for Aboriginal and Torres Strait Islander people (over 55 years of age), whereas Indigenous people make up more than 2% of the population and have significantly lower health status. Case conferences claimed reached 8-900/month by late 2001. In total, to 31 October 2001, 11,368 case conferences were claimed for 9,538 individuals. Almost three quarters were community based, with over 20% being for residents in aged care facilities. 1,908 residential aged care case conferences had been organised by GPs in the first year, November 2000 to October 2001, with a further 627 claimed for participation. Very few discharge case conferences were claimed (6% of all case 1

Those eligible for a health assessment are Indigenous people 55 years of age and older and all Australians 75 years of age and older.

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conferences). Two thirds of all case conferences were organised by the GP. Although 3,015 GPs claimed case conferences, 92% claimed fewer than 10 in total. Use of care plans was high GPs claimed a care planning EPC MBS item for 109,778 people during the first two years of availability. Uptake of care plans reached 15,000 per month in late 2001 and by early 2002 had reached 25,000 per month. The majority of care plans were prepared for people living independently in the community (80%), with 15% of claims being for a review of a care plan. One percent of all claims were for discharge care plans, demonstrating the continuing systemic barriers to including GPs in this activity. Care plans decreased from May 2002, primarily due to a substantial reduction in the number of community care plans being prepared (item 720) from a peak of 18-19,000 processed per month in March and April 2002 compared with 10-11,000 per month between June and November 2002. Review of care plans (item 724) declined only slightly over this period from 10-11,000 down to 8-9,000. [source: www.hic.gov.au, accessed 9 January 2003] This decrease in care plans appears to have stabilised now and may be associated with any or all of three factors. The first is the clarifications of patient eligibility and service criteria for community care plans issued in the Explanatory Notes of the May 2002 Supplement to the Medicare Benefits Schedule, the second is the progressive introduction of the new disease specific MBS items and the third is the removal of the care planning component of the PIP payments, with final payments being made in November 2002. Services relating to the new diabetes items were popular from November 2001 at a rate of 8-10,000 per month (with no corresponding decline in care plans) but they too decreased after May 2002 to a rate of 6-7,000 per month. The new asthma items had a slightly lower start at a rate of 2,000 per month in November 2001, reached a peak of around 5,000 in May 2002 and by November 2002 were around 2-3,000. The peak period for rendering care plans was February to April 2002, after the introduction of some of the new disease specific items. A decline in the claims processed for both the diabetes items and the care planning items after May 2002 suggests that the decrease in the preparation of community care plans was more likely to be due to the care plan clarifications in the MBS Explanatory Notes and the cessation of the PIP incentive for care planning, rather than substitution by the new disease specific items. However a definitive reason for the decline is not possible from this broad type of data and remains speculative. Limited numbers of patients received more than one EPC related service 19,749 people had both a health assessment and a care plan during the first two years of the availability of the EPC MBS items, with 383 of these also having a case conference. This was 6.9% of all people who received a service through use of an EPC MBS item. 1,784 had their first health assessment on the same day as the first care plan; 1,894 had a care plan first, and 16,071 had a health assessment first.

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SECTION 2: Major Themes Identified From Fieldwork Major themes identified from analysis of data collected through our fieldwork have been clustered according to the evaluation objectives. The themes are: Strategies to promote awareness, use and uptake of the EPC MBS items • Face-to-face, practice based peer education and support was considered the most effective mechanism for promoting awareness and uptake of the new EPC MBS items amongst GPs. • GP awareness of the items was high, but there was poor awareness amongst allied health providers and consumers. Consumer and provider satisfaction with items • Satisfaction with health assessments and care plans was high amongst consumers. • Health assessments were extensively used, and GPs found them acceptable, practical and appropriately remunerated. • Care planning was widely used, and while considered useful for some patients, there was confusion over the level of involvement of other providers, misinterpretation of the original Explanatory Notes in the Medicare Benefits Schedule book and, therefore, inconsistent implementation. There was some concern about the level of remuneration being inadequate for the time required to deliver a high quality plan according to the EPC Guidelines (RACGP) and MBS Explanatory Notes (May 2002 version). • Case conferencing was considered useful for a very small number of patients with highly complex care needs, but was seen as too complex, time consuming and poorly remunerated, relative to the effort involved, to be used extensively. • GP involvement in care planning and case conferencing in residential aged care facilities was limited but considered to be useful by those who use the items for this purpose. • Major barriers to GP involvement in discharge planning existed despite the availability of discharge planning EPC MBS items. Impact of the items on changes in practice and changes to systems of health care delivery • Allied health providers had major concerns about their limited role in care planning, and about lack of resources and remuneration. • Significant barriers to use of some items still existed. Concerns about time availability and workload were major issues for GP and allied health utilisation of the items. • The structure and nature of general practice created challenges for multidisciplinary activity. Impact of the items on quality of health care • There was strong support from all stakeholders for enhancing the capacity of general practice to respond better to the needs of older people and those with chronic conditions and complex needs. The following is a more detailed description of the results using the above main themes. Face-to-face, practice based peer education and support was considered the most effective mechanism for promoting awareness and uptake of the new EPC MBS items amongst GPs There was general agreement from Divisions, general practitioners and practice staff that use of practice visits by Division educators and peer educators, with tailored information and advice, was the

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most effective strategy for education and for promoting awareness of the items. Information provided in submissions also supported the effectiveness of this method. Most SBOs and Divisions started their GPESCL activity with development of information and templates for GPs to use for health assessments and care plans. Many ran group education programs for GPs initially, then eventually moved to practice based education where information became highly tailored to the needs of the practice and its staff. Most Division staff visiting practices were non-medical project officers, however two States used GP peer educators to do practice visits, with most others utilising peers in some capacity to spread the message about how to effectively use EPC items by speaking at CME events, writing in newsletters or running special “EPC” workshops. It was felt by many Divisions that peer education was more effective in this area as many GPs are more willing to listen to another GP about patient care issues and possible changes to their practice. Some Divisions used the potential financial benefits as a key selling point to GPs. One third of practices interviewed stated that financial benefit was a motivating factor, however, the likelihood of improved outcomes for patients and the desire to operate in a more ‘preventive health’ or ‘integrated primary care’based manner were, in 80% of case study practices, stronger motivating factors. GP awareness of the items was high, but there was poor awareness amongst allied health providers and consumers Documentation about the coverage of education activities shows that most GPs were exposed to some form of education, information or support throughout the GPESCL Program period. Those interviewed in practices were familiar with the full range of items available even if they were not using them. Interviews with Divisions, allied health providers, and SBOs highlighted the overall limited awareness of the EPC MBS items by allied health providers. There were, however, pockets of high awareness where significant effort had been made by the local Division or the State health department. Some Divisions reported actively promoting case conferencing with local health and community agencies. Most Divisions reported that their first priority was to raise awareness amongst GPs, believing that they needed to ensure GPs understood the items before others were informed. For many Divisions this major emphasis on GPs continued throughout the two year GPESCL Program period with little time allocated to informing allied health providers or consumers. The document review provided examples of activity with allied health providers in almost all Divisions, however this activity was often limited to particular types of services, for example mental health services, or was short-term or single contact activity. In addition to GP education outreach, other health professionals were actively involved in the education process. A key ingredient to the uptake of the EPC MBS items was the collaboration with “other service providers” and the opportunity to build relationships between GPs and these providers. (Rural Division Final Report).

The Department of Health and Ageing produced an allied health professional brochure 'promoting more coordinated care' (143,000 printed). Several submissions pointed out that the limited education for allied health providers was one of the key problems in the implementation of the items. Lack of resources and a high staff turnover were also identified by allied health providers as contributing to a lack of retention of information, awareness or understanding within their services. A small number of Division staff interviewed reported that their Board was reluctant to invest time and resources in working with allied health providers, believing that the resources given to Divisions should only be used for GP activity.

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The staff began receiving a significant number of care plans via fax from local GPs. They had no prior knowledge or experience of the EPC items and were confused and uncertain about their role… So they researched care plans. The RACGP information folder was very useful in informing them about the EPC items. They also arranged to meet with some local GPs to work out a process for handling the care plans. (urban dietician) The team believes that early intervention is needed to prevent crises and to keep people in their own homes. The team leader felt that, even though their involvement has been limited, and dependent on funding, that EPC items should be continued. However, she believes that health assessments need to be more consistent and that more education for allied health services should be done, as the information about the items did not ‘filter down’through the organisation. (urban allied health provider)

The key national strategy used for consumers was a brochure “how you can benefit” (497,000 printed). The brochures were widely disseminated through GP and consumer organisations. It was translated into 11 community languages and available on the Department of Health and Ageing website and through community organisations. Two years after the items were available the Department of Health and Ageing also funded the Council on the Ageing (CoTA) in South Australia to develop a peer education program2 for older people about health assessments. All Divisions and SBOs reported that they were advised early in the GPESCL Program period that a consumer awareness campaign would be conducted by the Department of Health and Ageing at some later stage. Most expressed frustration that this did not occur, stating this was a primary reason why they did not allocate resources and time to conduct such a campaign locally. Some State offices of the Department of Health and Ageing conducted local seminars and other activities to raise awareness with consumer and community groups in the first year after the items were introduced. Some SBOs and Divisions produced posters aimed at consumers for use in GP surgeries. Some Divisions visited consumer and self help groups (e.g. Victorian Divisions reported visiting 61 such groups overall), others educated their consumer reference group members about EPC. … ..many Divisions placed articles in their local paper or practice newsletters in an attempt to raise the awareness of EPC in the community. The lack of a comprehensive national consumer campaign (such as the Mental Health Campaign) has been a disappointment for Divisions and the SBO as it is felt that an excellent opportunity to raise awareness of the EPC items has been lost. (SBO Final Report)

Consumers interviewed were largely unaware of the items until approached by their GP with an offer of a health assessment or care plan. Allied health providers stated that communication with patients about the purpose and process of care planning and health assessments has been generally poor, leading them to spend time trying to explain the items to patients, with the added disadvantage of not being entirely sure of the purpose and use of the items themselves. GPs and Divisions reported there was very limited demand from allied health providers for GPs to participate in the care planning and case conferencing of other agencies. There was almost no demand from older people for health assessments and no demand from people with chronic illness for care plans. The lack of awareness by consumers and allied health providers was seen as a barrier to using the items by GPs. Satisfaction with health assessments and care plans was high amongst consumers Feedback from consumers about health assessments and care plans was generally positive with most consumers reporting increased confidence in their GP (86%), and in what they need to do about their 2

This program has been evaluated, with results not yet available.

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health problems (89%). Many believed they had learnt something from the process (68%) and had gained a better understanding of their conditions (74%). Two thirds believed they had received more help with their problems (66%) and had a better quality of life (64%) since the service was delivered. Health assessments were viewed as acceptable, practical and appropriately remunerated The common view was that health assessments were easy to understand and straightforward to use. Some Divisions and community health agencies had provided a pool of nurses to practices at minimal charge to assist practices in “trying out” the health assessment item. Almost all GPs interviewed had begun their use of EPC items by trying the health assessment items, and most GPs were keen to do health assessments for all of their patients 75 years and over. Almost two thirds of practices we visited used the services of a practice nurse to undertake the information gathering component of health assessments. They believed that the practice nurse was key to the successful implementation and integration of health assessments or care planning into practices. However, in a third of practices, GPs undertook all the health assessments on their own. These practices were evenly spread through urban and rural areas and across practice sizes.

CASE STUDY SUMMARY Practice characteristics Location: Suburban area of capital city Population: Many young families and significant number of people of European background Number of GPs: 6 FTE GPs including 5 full-time, 7 part-time and 1 registrar Staff: 7 practice staff including 3 full-time and 4 part-time reception and administrative staff Status: Accredited, registered for PIP, computerised EPC profile: Use health assessments, community care plans, and residential aged care plans GPs in this practice undertook all their own health assessments, some in-home and others in the surgery. One GP preferred home visits and scheduled them on his afternoon off, finding that doing them in consulting time added too much pressure. A second GP did all assessments in the surgery, where it was easier to do some of the measurements and testing. A shortened home visit followed to assess medication, diet and safety, with all reviews unless there were particular circumstances, done in the surgery. Both GPs found the health assessments to be the most useful of the EPC items and maintained that they were a meaningful activity to improve understanding of how patients are affected by their illnesses, and of their broader needs. Just over half the practices conducted health assessments in the patient’s home because they reported that it allowed them to identify hidden medical, environmental and support issues. About a third preferred to do the assessments in the surgery where they had direct access to testing equipment as needed and could minimise disruption to their schedule. The majority of GPs felt that the in-home assessment was the best and most effective, however those who did surgery-based assessment felt they were still quite useful in identifying needs and issues.

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Most GPs felt that they were adequately remunerated for the service, with the volume of items able to be done with practice nurse assistance covering the additional costs to the practice. Others (generally those not using a nurse) felt that health assessments were not financially viable and a burden on the practice. Other positive comments GPs and practice staff made about the health assessments included patient and carer satisfaction, reinforcement of clinical management, identification of previously hidden issues, improved relationship with the patient, a comprehensive health record for the patient and GP, and the preventive nature of the exercise. Know that help is there if/when I need it. Great for some people, no real difference for me but good to do (consumer, health assessment) Insight into my own condition now. Very happy with it. Sometimes slipped before when shopping, but know I have to stick with it now (healthy eating) (consumer, health assessment)

Comments received via submissions and from Divisions also confirmed that satisfaction was highest for health assessments. Care planning was considered useful for some patients, but there was confusion over the level of involvement of other providers, misinterpretation of the original MBS Explanatory Notes, inconsistent implementation and some concern about the level of remuneration The main criticisms of the care plan item by GPs, Divisions and stakeholders were the complexity of the requirements, the amount of paperwork involved and the time needed to review medical notes and test results to achieve a quality care plan. Many GPs felt that there was a lack of systems to support them to do care planning that met the MBS Explanatory Notes and item descriptors, and that this together with long waiting lists and slow or no responses from allied health providers made the care plans too cumbersome. Divisions stated that they found it difficult to get accurate, consistent advice and information about the requirements, and reported that GPs were confused about what they had to do. They also found that while care plans seem to provide better information to other providers than straight referrals, the quality of some of the care plans they had seen was poor. Many appeared to fail to meet the criteria for involving other health providers. Allied health providers agreed that this was an issue, adding that GPs did not understand the way allied health providers operate. The submissions supported the concern that most GPs lacked understanding of collaborative assessment and planning and of multidisciplinary care. The pharmacist approached the local GP to encourage him to refer patients to him for in-home medication reviews. The pharmacist found it quite difficult to “get the ball rolling”, the main problem being that GPs do not think of pharmacists as a part of their routine referral pattern. This is still a barrier. The pharmacist feels that he and the GP have been educating each other and providing a stimulus for further learning. He finds that they can bounce ideas off each other, and this is a very positive thing. (rural pharmacist)

Almost all GPs interviewed took on the entire care planning process themselves, with the impact on their own time being substantial, given that most would do the paperwork and background at night or on their days off. Only some GPs (about a tenth) used their practice staff to do patient identification and contact, allied health providers contacts and referrals. Consequently these GPs were generally able to do the care plans without too much spillage into their own time.

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CASE STUDY SUMMARY Practice characteristics Location: Large coastal town Population: Mixed population Number of GPs: 9 FTE GPs and registrars Staff: Practice staff includes a practice manager, 8 nurses, 1 EN, 1 home health assessment nurse and 10 clerical staff Status: Accredited, registered for PIP, computerised EPC profile: Use health assessments, care plans and case conferences GPs in this practice worked closely with their local Division and were used as a resource by the Division. They had ongoing involvement with the Division and had been involved in meetings and discussions about the items prior to their release. They used health assessments extensively, initially trying them out in the surgery, but eventually employing a nurse to do the in-home component. They identified patients opportunistically rather than by generating computer lists and found that the assessments identified hidden problems. The GPs researched care plans thoroughly before using them, in an effort to ensure that they were using them correctly. In the early stages, a number of patients with chronic illness, after hearing about them from allied health providers and other patients, changed doctors to come to the practice, asking for care plans. They found them to be most useful for patients with terminal illness, patients with complex conditions who were seeing a number of providers, and patients with developmental disabilities. Care plans “turned chaos into organisation for patients”. As a result of the care plans and health assessments, the practice found that the same number of patients were being seen, but the visits were less frequent and the consultations longer. More patients were seen on recall and there were fewer walk-ins and fewer patients running out of medication. The GPs stated that the work was more professionally satisfying and the patients loved it. Half the practices we visited reported using care plans on patients with diabetes, and this was often how they started using care plans, believing that this would be a good measure of their effectiveness. Some GPs reported that despite their patients only having one condition, they felt that there was complexity in relation to the management of that condition and that if there were more than pne other provider involved, then that meant that patient became eligible. Some care plans were clearly being done on patients with single conditions, not multiple conditions or needs. However there did appear to have been a move away from this approach, with only a few GPs persisting with only doing care plans on their patients with diabetes or mental health issues. GPs were referring patients to them who were already on their books, had good control and did not need the extra service as well as those who did need the help. There was a lack of discretion on the part of the GPs. (urban diabetes educator)

In two practices, nurses undertook the care plans in consultation with the GPs. This model was very strongly supported by these practices, with very positive feedback from all concerned, including patients. The GPs involved reported that it allowed them to practice proactive medicine without sacrificing patient access to acute care. They felt the nurse could spend time identifying unmet need, issues that were not already apparent and could put in place supports and services to ensure issues 25

were managed thereby averting the need for acute intervention or even hospitalisation or admission to care. Positive comments about care plans included that they: • provided a complete and up to date history; • ensured that patients issues were listened to and needs met appropriately instead of in an ad hoc manner; • encouraged a comprehensive approach to needs; • influenced the way GPs approach their patients with chronic conditions; • increased patient involvement; • had the capacity to reduce hospital admissions for preventable events; • created the opportunity to engage with other health providers; and • were a useful training tool for Registrars. The nurse received care plans from GPs, most of whom they already worked with prior to the introduction of the items. She felt that the care plans were really good and helped them to understand the physical problems of psychiatric clients as well as the mental health issues. (urban allied health provider)

Consumers who had received a care plan named a range of aspects they liked, including that it helped them feel they had some control over their health, that other providers and specialists were better informed and that it was reassuring. It is easy to reference for other specialists. Had a recent emergency and was taken to hospital, my daughter knew where the care plan was and gave it to doctors there… If you are stressed, unwell or unconscious it means you can’t forget anything, as it is all there. I now take the plan with me to hospital every time. Keeps things relevant and recent (consumer, care plan)

Whilst most GPs who commented on remuneration felt the care plan payment was adequate, there were a small number of GPs, who spent several hours reading histories, discussing issues with the patient and contacting other providers, who believed the fee was inadequate. Perceived changes to the guidelines, which took place in May 2002, resulted in approximately a fifth of the practices believing that they would opt out of care plans, stating that they were now too hard to do, with unreasonable demands for allied health involvement that would be impossible to meet. Over 60% of practices reported they would continue using care plans into the future, but most believed they would only use them for a few selected patients as needed. The remainder either had never done any care plans or were undecided. Case conferencing was considered useful for a very small number of highly complex patients, but was seen as too complex, time consuming and poorly remunerated, relative to the effort involved, to be used extensively. GP feedback indicated that they found case conferences too difficult to arrange, although they would be happy to participate if someone else organised them. Both allied health and GPs noted that the logistics of getting three or more people to meet or speak at the same time were very difficult and would mitigate against case conferences being possible for any more than a small number of highly complex patients. Over half the practices interviewed had claimed for case conferences, which is higher than the broader general practice community. The GPs who did use them found the item to be very useful for patients with particular issues including drug dependence, mental illness, children with ADHD, palliative care, chronic pain, osteoporosis, housebound elderly patients or for adolescent mental health problems. One

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GP conducted case conferences for all residents of a local nursing home, involving the pharmacist and facility staff. Divisions that had taken a role in arranging case conferences acknowledged the difficulty of the task.

CASE STUDY SUMMARY Practice characteristics Location: Suburban area of capital city Population: Rapidly growing area, young families and significant elderly population Number of GPs: 8 FTE GPs Staff: 3 practice staff including casual and full time receptionists and 2 Registered Nurses (1 as practice nurse and 1 specifically for health assessments) Status: Accredited, registered for PIP, computerised EPC profile: Use health assessments, care plans and case conferences The practice participated in a program for high school students with problems. They were involved in case conferences with various providers and support people including teachers, year coordinators, an educational psychologist and/or clinical psychologist or psychiatrist, speech pathologist and so on. The case conferences were arranged by the Division at a rate of one per school term. Participants agreed that they are very valuable with a great deal of benefit deriving from the team approach. GP involvement in care planning and case conferencing in residential aged care facilities was limited but considered to be useful by those who used the items for this purpose One third of practices had claimed the items related to care planning or case conferencing in aged care facilities. These doctors had, in some cases, systematically worked though all residents of the facility, in conjunction with the director and nursing staff. They had developed systems to identify and refer all new residents for assessments.

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The facility has found use of the items very positive. It is felt that the care plans have led to better communication between staff and doctors, have given the doctors a better understanding of the resident’s needs and of the role and obligations of the staff, and have prevented the need for emergency calls when the patient’s prescription has expired. They have helped to reduce the number of medications. They would like to see all other doctors developing plans for their patients. (rural residential aged care facility)

The residential aged care facility staff interviewed indicated that the involvement of GPs in their care planning and case conferencing activities would increase over time as the sector gained better understanding and experience. Major barriers to GP involvements in discharge planning existed despite the availability of discharge planning EPC MBS items Most GPs said that, while they would be happy to participate in a discharge care planning meeting, it was clearly up to the hospital to arrange and inform them about it. A number of GPs, particularly those in rural practices, already participated in discharge planning and had strong connections with local hospitals and regional health services in the area. Those who did use the item found them useful. Some hospitals enabled GPs to participate by using a phone hook up during the meeting.

CASE STUDY SUMMARY Practice characteristics Location: Rural town 1 hour from a capital city Population: Mixed Number of GPs: 7 FTE GPs including one registrar Staff: 8 practice staff including practice manager and deputy practice manager Status: Accredited, registered for PIP, computerised EPC profile: Health assessments, care plans, discharge care plans and case conferences Discharge care plans were used for patients in the acute medical ward of the local hospital, particularly where they had a complicated history, challenging current circumstances and needed safety nets and support on discharge. They felt that a good discharge plan had a distinct goal, was focused and was collaborative in order to manage the practicalities of discharge for the patient. GPs found that case conferencing was useful for hostel residents and that they and the discharge care plans fitted well with the way rural GPs work. Divisions and SBOs agreed that discharge case conferencing and care planning was too hard for GPs to organise or participate in. The mismatching of systems between hospitals and general practice is a significant barrier. GPs reported that they cannot respond at short notice to participate, they cannot be on site for conferences and planning and that they needed to know that their patients were in hospital as early as possible to be able to think through the issues for discharge. Some SBOs and Divisions spent considerable time negotiating with State health authorities and hospitals about general practitioner involvement in discharge planning, however while much of this work was already occurring prior to the advent of the items, little progress has been made. During 2002, the Department of Health

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and Ageing has entered into jointly funded pilot projects to improve and promote use of EPC hospital discharge items with a number of State health departments. Allied health providers had major concerns about their limited role in care planning, and about lack of resources and remuneration Some allied health providers thought some GPs had been very good at establishing relationships with them prior to starting use of the care planning items; however allied health providers identified major concerns with their role in care planning. The biggest concern was about requests to contribute to care plans for consumers they had no prior knowledge of, and with whom they had not done an assessment of needs. They felt this was not appropriate, as they needed an opportunity to assess the patient prior to developing a care plan. The MBS Explanatory Notes required the negotiated and agreed involvement of an allied health professional in the patient’s care, but many GPs appeared not to understand the need for assessment as part of this process. Allied health professionals stated that, although the care planning process has made GPs more aware of other services in the community to support patients, inappropriate referrals were common due to over enthusiasm and not fully understanding the role of allied health services or the way they work. They see saw duplication of effort regarding assessments and variable levels and standards of information provided with referrals and care plans. They suggested that these issues could be addressed through better communication and agreement about information to be gathered and shared. Better education about what allied health services provided and how they worked was important at the local level. The psychologists feel they cannot comment on a care plan for a patient unless they meet the person at least once. The assessment should really come before the care plan. (rural psychologists)

There was also concern that follow-up action after care plans to identify problems and needs for a service was not done by some GPs, making the processes meaningless. Some justification for this concern was found in the HIC data, which indicated limited use of care plan review items. Only 20,371 reviews had been conducted compared with 107,181 community and 1,151 discharge care plans prepared over the two-year period to 31 October 2001. By July 2002 there had been 98,002 reviews performed and a total of 243,828 community and 2,264 discharge care plans prepared. During this extended period 240,502 people had a care plan (prepared, attended, or reviewed) with only 76,744 people (32%) having more than one. Given that there was an ability to conduct reviews every three months after a care plan was written, it would appear that fewer multidisciplinary reviews were undertaken than allowed. Some GPs interviewed stated that they did not think that three monthly reviews were clinically warranted. Time availability and workload were major issues for GP and allied health utilisation of the items. Significant barriers to use of some items still existed Demand for acute and episodic care was named by all stakeholders as being a major barrier to GP uptake of the items. Many considered that, while GPs continued to have full appointment schedules, they would not have the time to consider use of the items, let alone undertake health assessments and care plans. GPs and allied health service providers agreed that heavy workloads, high allied health staff turnover and lack of time were significant barriers to using the items. Feedback from Divisions confirmed these issues and the additional complication of what was perceived as complex paperwork and bureaucratic requirements.

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Going through each one (care plan) will take time and to do them well she needs to spend a lot of time looking up information about interactions etc. It is time she does not have. (urban pharmacist) The doctors say that they are very busy; there is no time and too much paperwork. (urban allied health provider)

Other issues identified by Divisions, GPs and allied health providers alike included rurality, low provider numbers, patient workload, geographic isolation and issues specific to the Aboriginal and Torres Strait Islander population, including cultural inaccessibility. This was especially so for the low uptake Divisions interviewed. Not all GPs in these low uptake areas were eligible to use the items, as they were salaried GPs in hospitals and Aboriginal Medical Services, with no agreement in place to access Medicare. The GPs that were eligible already carried extreme workloads. Allied Health and Aboriginal Medical Services had similar issues with a highlight on the difficulties of retaining staff and high workloads. There were also large numbers of seasonal, short-term or transient patients. Some practices in the low uptake Divisions mainly dealt with a seasonal surge of tourists or transients who used GPs on an episodic basis only. The low uptake Divisions reported undertaking a variety of opportunistic activities in an effort to encourage further uptake of the items, including promoting the employment or use of practice nurses to co-ordinate and manage the use of the items, and using their More Allied Health Services (MAHS) programs as a way to promote and introduce the items to GPs.

CASE STUDY SUMMARY Practice characteristics Location: Outer metropolitan area Population: High proportion of non-English speaking residents Number of GPs: Solo practice Staff: 1 receptionist who also arranges Meals on Wheels, home nursing and other services Status: Not reported EPC profile: Has used health assessments and care plans, but does not use any items at all now The GP became aware of the items through his role in the Division where he was part of the development and implementation strategy group. In spite of this involvement, he felt unsupported by the Division. He had done health assessments and care plans but now rarely used the items, which he felt were developed the wrong way, with too many forms and too much complex and complicated information. He believed that care plans increased costs without benefits. He was a methadone prescriber, but did not feel that the care plans were helpful in the management of drug dependent people. He did not feel that patients wanted care plans and referred all new diabetes patients to the diabetic educator. Perceived changes to the MBS Explanatory Notes in May 2002 were felt by GPs to have complicated the care plans too much, and a significant number stated they would choose to stop using them. The confusion and lack of understanding about care planning was high, as was fear of doing the “wrong” thing in relation to claiming the items. 30

The structure and nature of general practice were mitigating factors against multidisciplinary activity SBOs, Divisions of General Practice, allied health providers and GPs all acknowledged that historical and current models of practice were constraining the ability of general practice to better integrate with the rest of the health care system. It was acknowledged that the Commonwealth funding of general practice and the State funding of hospitals and allied health services had created two different systems that had difficulty interacting. There was often tension between the priorities of each sector. The private practice nature of general practice and the public sector environment of many allied health services also served to make collaboration challenging. GPs frequently raised the lack of availability of allied health personnel after hours when they had time to talk on the phone or do the paperwork associated with care plans. Allied health providers expressed frustration that they could not get through to GPs. Pharmacists and other private allied health practitioners were concerned that they had little time to respond to GP requests for involvement in care plans, they also knew they would not be paid for the time, but the GPs would. Hospital staff expressed the view that they could not accommodate GPs’needs for advance warning about a case conference for discharge due to the immediate need for decisions, with GPs frustrated that they were unable to juggle appointments to even make the space for telephone conferences on short notice. Residential aged care facilities stated that engagement with GPs around care planning was new territory and there were some clashes of systems and priorities, but they could be overcome with patience. The traditional hierarchical model in medicine was also a barrier. There is a limit to the care plan model. GPs will rarely see allied health as equals. There is a risk that the allied health workers will remain passive and subservient rather than risk being offside with a GP. (rural diabetes educator)

Consumer organisations felt that having a health system provided by national, state, territory and local government as well as by private providers made for a serious lack of coordination. The blame was shifted from one level of government to the other and the consumer and their family were left wondering how to get the care they needed. Systems within general practice to enable health assessment, care planning and case conferencing were in early development. Most GPs stated that, since the introduction of the EPC MBS items, they had made changes to the way they managed their workload in order to accommodate the items, with over half the case study practices employing extra staff, or extending the hours of existing staff to assist with the additional tasks. Better use of computer systems for recall and reminders was also identified. Divisions, in particular, commented that these systems and reorganising of workloads and duties were essential for general practice to move from the notion of a reactive GP to a comprehensive general practice service offering preventive care and effectively managing their more complex patients with chronic illness. General Practitioners, Divisions and practice staff agreed that, where general practitioners employed practice nurses to undertake the information gathering component of health assessments and/or to assist with care plans, case conferences and discharge planning, the impact on GP workload was minimised, and the relationships with allied health providers were, to some extent, enhanced.

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CASE STUDY SUMMARY Practice characteristics Location: Suburb of capital city Population: High proportion of aged in the community, with significant DVA clients Number of GPs: 7 FTE GPs - 13 GPs in total with 11 claiming EPC items Staff: 22 practice staff including practice manager, treatment room assistants, 3 nurses of whom 2 are involved with EPC Status: Accredited, registered for PIP, computerised EPC profile: Claim all items The practice mainly used health assessments and care plans. GPs found that they needed a person specifically dedicated to assist with health assessments as they and existing nursing staff did not have the time to dedicate to the items. Having employed a nurse experienced in EPC they set a target of as many as possible of the eligible patients having health assessments, and 10% of patients having care plans (in line with the then PIP incentive). Participating GPs referred complex patients to the nurse, after discussing the options of health assessment or care plan. The nurse made time to see the patient in their home and prepared notes for discussion with the GP. The patient was booked in to discuss the plan after which it was implemented. Often the referrals and much of the implementation occurred prior to the patient’s next consultation, and the nurse made the referral if it was urgent and the patient agreed. The GP and nurse agreed that the practice had a better history for the patients who had a care plan or health assessment. The patient received more and better time and advice, patients were better managed when using the nurse as a central liaison person and the practice accessed a greater range of community activities and services, helping to reduce the social isolation of some patients. The practice now used a more team-oriented approach to health care and provided a monthly patient education program with positive feedback. A number of Divisions employed their own allied health providers, including mental health workers, podiatrists, diabetes educators and psychologists, on a contract basis, making their services available to GPs where the availability of those services are lacking or infrequent. The submissions reported that GPs generally had a limited understanding of the roles of providers in the rest of the health care team and that allied health providers did not understand the requirements of the items on GPs. Several organisations believed that there was a great deal still to be done to enable collaboration between GPs and allied health providers at the local level, but that systems were now being developed. The Primary Care Partnerships in Victoria and the Area Health Service partnerships with Divisions were given as examples of these systems. There was strong support for enhancing the capacity of general practice to respond better to the needs of older people and those with chronic conditions and complex needs Divisions, GPs, practice staff, allied health providers and consumers agreed that the items provided the opportunity for more holistic health care. Several practices reported that they were more aware of and actively practising preventive health care in contrast to the more reactive health care practiced prior to the introduction of the items. 32

Many GPs commented on the items as rewarding them for the good practice they have always done without remuneration in the past. Many commented that it was good to have the items available so that they could take the time to gather a comprehensive history and step back and look at the bigger picture with their patients rather than reacting to acute episodes.

CASE STUDY SUMMARY Practice characteristics Location: Regional rural town Population: Mixed population est. 31,000 Number of GPs: 8.2 FTE GPs and a registrar Staff: 9 practice staff including 1 RN, 1 OT/RN, practice manager, 6 receptionists and others Status: Accredited, registered for PIP, computerised EPC profile: Use health assessments, care plans, case conferences, discharge care plans and residential aged care plans, but have mainly focused on health assessments and care plans for diabetes, asthma and chronic and complex conditions The practice employed an EPC coordinator/nurse, who was responsible for both EPC and PIP. He ran the program with and for the GPs, providing training and updates on the items and new initiatives relating to EPC and PIP. He assisted with all health assessments, mainly in the home. He also did all preparation including identification of patients, relevant items needed and basic documentation. He had developed a proforma for the GPs to use and handled referrals, contacts and follow-up. The practice also had a diabetes educator on site, shared with a number of other practices in the region. The educator was employed by the Division and provided comprehensive input to care plans, and diabetes education. The Registrar indicated that the items were useful both clinically and as a tool for managing diabetes. They were particularly helpful for new GPs to help them get started and to ensure that they got everything done. The practice had integrated the items into daily practice. GPs found that they received more and better feedback on patient needs. GP education had increased to keep up with the items and the focus had moved to proactive rather than reactive health care. They now had more detailed and ongoing reviews of patient records to help determine eligibility for services. Extra time provided when a health assessment was done or a care plan was prepared, was named most often as being the aspect consumers valued. They also valued the reassurance, the thoroughness of the process and the way it strengthened their relationship with their doctor and gave them a better sense of control over their health. GPs also liked the improved relationship with patients and the preventive approach the items engendered. Consumers, allied health providers and GPs all supported the sharing of information amongst those involved in patient care.

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I take it to hospital with me. All my medication, history etc are there and makes it (admission) so much easier. I felt the GP was interested and I felt more worthwhile, my self esteem was low due to illness, but I feel much more confident now. Everyone should have one done – it makes you aware of your GPs concern and that you are not just in there for 10 mins for a fee. (consumer, care plan)

Divisions were supportive and enthusiastic about the opportunities the items offered, such as payment for non-patient contact time, and promoted them extensively through the GPESCL Program. Some reports from SBOs and Divisions emphasised the use of the EPC MBS items within a range of their existing programs, especially those that involved multidisciplinary care, such as schools, drug and alcohol and mental health programs. However, there were GPs who were still wary of the underlying motivations of government in introducing the items with fears expressed for the future direction of general practice. Some feared the items, along with the PIP, were the start of introducing salaried doctors in general practice, despite the items being very much a part of the fee for service system.

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Discussion Promoting Awareness, Use and Uptake We conclude that the GPESCL Program was very effective at raising awareness among GPs and GP organisations. However, it was much less effective among allied health professionals and their organisations, and remains largely unknown among consumers and consumer groups. GPESCL contracts expected much more than education, and had broader targets for education that just GPs. The results show the lower priority given to the community linkages part of the GPESCL contracts. The intended focus of the items was to “provide more preventive care for older Australians” and to “improve care coordination between general practitioners and health and other professionals providing care for people of any age with chronic conditions and complex care needs” (DoHA website accessed 25/11/02). However, a major focus of education and support activities to GPs was on the processes and administrative details of claiming the EPC MBS items and the potential financial benefits to the GP. Therefore there was limited emphasis on the services and activities that could be undertaken to implement “a multidisciplinary approach to health care through a more flexible, efficient and responsive match between care recipients' needs and services”(DoHA website accessed 25/11/02) Many of those charged with promoting the items to GPs and others, had a limited grasp of the philosophy and intent of the EPC MBS items. The late availability of the RACGP EPC Standards and Guidelines, the pressure from the officers within the Department of Health and Ageing (through funding contracts for GPESCL activities) to achieve high levels of usage of the items, and the conflicting and often unclear advice from various sources were also significant factors in why the understanding was limited. Divisions and SBOs showed an increasing understanding of the intent of the items and gained sophistication over time regarding how to work with practices to assist them to utilise the items effectively. Practice staff have generally had a limited role in the delivery of services through the items, with few being well informed during the first two years. However, practice staff have increasingly become the target for education and awareness strategies during 2002. Education strategies amongst allied health providers and consumers had a very minor impact on awareness. Many Divisions simply ran out of time to properly address the linkages part of their contracts and many had made the assumption that the Commonwealth would take care of the consumer awareness strategies. There was no overall co-ordinated strategy for making allied health providers or consumers aware of the items, leaving the demand side of the equation unaddressed. It should be acknowledged that some Divisions did make concerted efforts to engage with allied health services, especially those who brought allied health providers and GPs together in practices or at workshops and educational events. However most Divisions appear to have allocated minimal resources to the task, or left the activity until much later in the GPESCL Program period. There is still potential for information and awareness strategies to be implemented with consumers, to be conducted strategically through older person’s organisations initially, regarding the benefits of a health assessment, then through organisations that support people with chronic illnesses regarding care plans and a GP role in assisting them to best manage their conditions. Older people may potentially be the strongest vehicle to promote uptake. Peer support and education programs run through older person’s organisations such as the CoTA have shown that older people are effective

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communicators of health messages to their peers. They have strong interests in health care and many still have wide and effective networks to channel information through (Council on the Ageing 2000). The work that could be done with allied health providers is still significant and does need to continue. There are some strategies already tested in Divisions that could be duplicated elsewhere. The initiative of the Victorian Department of Human Services to work jointly with Divisions to bring together allied health providers and GPs to explore about multidisciplinary activity and care planning could be implemented nationally. Other local strategies that appear to have been effective are where the Division has facilitated allied health contact with practices who had patients in common. These contacts have been highly practical and generally result in a care plan service being initiated. The notion of bringing allied health to general practice rather than GPs having to initiate the contact does appear to have some merit, making it more convenient for the GP and educating the practice and the allied health provider about how each works. In summary, there are some key lessons for future rollouts of such initiatives. They are: • Focus on the broader context and intent of the initiative with background information available as early as possible. • Work with practice staff better to encourage consideration of how practices could be reorganised to better accommodate care of those with chronic and complex illness. • Engage State health authorities and allied health providers at the local level sooner and more effectively. • Create awareness, and hence demand, in the community for the new services through community education and awareness strategies. Awareness and understanding will inevitably increase over time now that almost three quarters of GPs have claimed at least one EPC MBS item. Use of the items will be affected by demand driven by patients who learn of the services by word of mouth, especially health assessments. Divisions may drive practice and system change through their activities to overcome the barriers identified through the evaluation. Recommendation 1 Future promotion of the EPC Items by the Department, Divisions, professional groups and others should focus on their use within the broader policy framework of care for older Australians, and people with chronic and complex conditions

Satisfaction with the Items Consumer satisfaction with health assessments, care planning and case conferencing was high. GPs and practice staff views about health assessments were also positive. The health assessment EPC MBS items were considered easy to use, and the assessment itself could generally be accommodated within current practice models and activities i.e. relevant components delegated to a nurse or other professional, and done without reference to other health providers/services. With such high acceptance of health assessments by GPs, practice staff and consumers, and strong evidence about their effectiveness, there would be benefits to the broader community of strongly promoting their usefulness as an annual event for all people 75 years and over (and Indigenous people 55 years and over), but especially so for those who have some risk factors apparent. There is a need to increase the number of health assessments performed in order to see a major impact on access of older people to appropriate health care. There is strong evidence from the 36

systematic reviews of randomised controlled trials supporting the use of health assessments that gives us confidence in recommending their increased and more regular use. Health assessments can also support a population health approach within defined populations with targets and incentives. Recommendation 2 GPs should be encouraged to conduct health assessments annually on eligible patients. The issue of health assessments for older Aboriginal and Torres Strait Islander people is a complex one, with there being a general view that comprehensive assessments for Indigenous people would be better done at earlier ages. As the current health assessment is about better care for older people, it would be preferable to consider the promotion of such overall assessments for all Indigenous people utilising other MBS items such as the new item suggested below. The appropriate place of care plans in a general practice has caused confusion from their introduction, but the clarifications in May 2002, although widely misinterpreted as significant changes, have brought home the message about the explicit involvement of other providers and the complexity of the needs of eligible patients. Generally GPs’experience of care plans is that they are useful for some patients but they would not use them frequently, unless they felt the circumstances warranted the time and effort to meet the requirements and accommodate the paperwork. Although the paperwork involved in developing and recording a care plan is higher than for normal clinical care, it is generally in keeping with the complexity of the patient and the need to review histories thoroughly, document issues and future management and communicate with other providers and the patient about the plan itself. Very little of the “paperwork” is actually to do with bureaucratic accountability for the fee for the service. The paperwork that is needed is part of good clinical practice for this type of patient, but in addition, because the clinical practice requirements are detailed extensively in the MBS book they do form a basis upon which a GP can demonstrate that he/she has met the requirements for claiming the item. Some GPs have focused on the second aspect rather than seeing the paperwork as being necessary for the first. The value of the community care plan item has been the opportunity and incentive for the GP to spend time in the assessment and review of patients with chronic and complex diseases without the loss of income associated with use of the prolonged consultation item (Level D). Clearly the majority of GPs understand about case conferences, but the fact that they do not use the items extensively is a comment on their complexity and practical difficulty. They will continue to be used infrequently by the majority of GPs. Those who do continue to use them and those who will use them occasionally will do so due to a specific situation that requires simultaneous discussion of a case amongst several providers about a patient with complex needs, which is entirely consistent with their intent. There was strong support for relaxation of the requirements to allow discussions over a period of time, however this style of case discussion is already possible through the care plan process. The clarifications to the MBS items in the Explanatory Notes in May 2002 Supplement to the Medicare Benefits Schedule, the introduction of new chronic disease specific items and the changes to the PIP have all created confusion, frustration and generally had a negative impact on attitudes to the EPC MBS items, and to care planning in particular. A period of stability would be highly desirable, however there was also a strong view expressed by GPs in particular that some simplification of the requirements for care planning is needed.

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Recommendation 3 The EPC Item Descriptors and Explanatory Notes for health assessments and case conferences should not change in the foreseeable future to ensure some stability. Trends in uptake should continue to be actively monitored. Further effort is necessary to educate GPs and clearly describe the practice and principles of multidisciplinary care planning and co-ordination of care. Most GPs would appear to have limited experience in, and understanding of, collaboration with other providers around patient care, beyond referral to their specialist colleagues and a small range of allied health or home care services. Without this understanding, the interpretation of the requirements of the MBS item for care planning will be too diverse. Greater emphasis is needed in the MBS Explanatory Notes in relation to community care plans to ensure GPs claim the item for patients with multiple chronic illnesses and relatively complex needs. The emphasis should be on the complexity of the person’s needs and the number of other health providers currently involved or potentially needing to be involved in an ongoing way, rather than on chronic illness itself. One of the key messages needs to be about the type of patient that would benefit the most from the use of the items, so in the case of care planning it would be about patients seeing many specialists and other health providers and the need to co-ordinate their care and treatment, or the patient who has multiple conditions and difficult social circumstances. The other emphasis could be on the GP role in brokering or accessing services on behalf of their patients who have high needs. Recommendation 4 The MBS EPC Item Explanatory Notes for care plans should be clarified and simplified. The intent should remain the same, however minor changes could be made to more clearly spell out practical expectations. Satisfaction with care plans would improve if GPs were explicitly allowed to delegate appropriate tasks to another party, as they can with the information collection component of a health assessment. It would be preferable to allow “substitution”by a nurse with community experience and appropriate skills, for the technical parts of the care plan process, but still requiring the GP to conduct the clinical aspects of the care plan. Recommendation 5 For care plans, the use of a nurse and/or administrative staff for the technical components of the service should be allowed and encouraged. Much of the care planning the evaluators saw was not multidisciplinary in nature, i.e. the plans had been devised entirely by the GP although some did incorporate the views of other providers. The care plans that resulted from this approach were not necessarily poor quality, nor did they involve deliberate misuse of the items. Both GPs and consumers viewed the process of the GP spending reflective time with the patient positively as it allowed for a comprehensive review of needs and issues, resulting in an appropriate and useful plan. There is a need to recognise the value of the GP discussing with a patient the patient’s health issues and needs and developing a plan for treatment and services. An MBS item could be created to reward this activity, leaving the existing care planning items for a small number of high need, very complex patients who require intensive work by a number of different providers. The new MBS item could be for the development of a disease management plan. It could be rebated at less than the current care plan

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item (720), but at a level commensurate with the work involved. See Diagram 1 for how this item could fit with the existing EPC MBS items. Recommendation 6 A new MBS EPC Item should be created to encourage the development of care plans for patients who have a chronic condition, but for whom multidisciplinary team care is not required. This could be known as a disease management plan.

Practice and System Change The evaluation has identified a number of positive impacts on practice and systems both within practices and between general practices and allied health service providers. While it is too early for wholesale practice and system change to have occurred yet, the introduction of the EPC items has changed the environment within which general practice functions. Multidisciplinary care, prevention, and structured care are now on the general practice agenda and increasingly being discussed. The uptake of health assessments by over 50% of GPs is a substantial achievement. Many practices have clearly set up new systems, including systematic use of practice nurses and information technology innovations, to achieve this. Some practices have introduced substantial changes to accommodate care planning, but there has been little change in relation to case conferencing. The evaluation did not find many examples of substantial, systematic practice change; indeed, GPs are often doing EPC work in addition to their standard workload. It will take time and effort for large-scale change to both practice and systems so that EPC approaches can be considered an integral part of general practice care. It was the view of the consortium that more could be done to work through the practice management and administration staff regarding effective systems and practices to enable better management of patients with chronic conditions and complex care needs. Technological support for such an approach in general practice is also still lacking, resulting in duplication of effort and poor quality tools. Support for re-engineering practice and finding better ways to manage demand and time are needed. Practice managers could take a lead role in establishing systems to assist the GPs to manage their time and workloads to accommodate care planning and health assessments. Where practice managers are not in place, consultancy advice through Divisions may be helpful and cost effective.

Impact on Quality Many different individuals and organisations provide services to the elderly and those with chronic illness, and coordination is not an easy task. Both State and Commonwealth governments have introduced initiatives to improve the health outcomes of people with chronic illness. Both levels of government need to work more closely together to ensure these initiatives are compatible. There is also a need for much stronger and persistent strategies for enmeshing general practice with the State primary care system. Currently Divisions are a key structure with the capacity to encourage and support collaboration and integration of primary health care service delivery at the regional and local level. There is also potential and capacity within regional and local health services funded through State health authorities, to encourage and support collaboration. For maximum impact, both general practice and State funded and private allied health would need to invest in building sustainable links and models that enhance the care of people with chronic illness and complex care needs.

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Diagram 1: Possible Pathways for Management of Patients with Chronic Illnesses and Complex Care Needs

Stra teg ic identifica tion ofpa tients throu g h da ta ba s e a nd m edica l record review

Sta nda rd Cons u lta tion (Opportu nis tic identifica tion)

Pa tient s elf-referra l for a cu te or ong oing needs

Patient has chronic conditions and potentially complex needs and risk factors

Patient has 1-2 conditions and no co-morbidities

DISEASE/MEDICAL MANAGEMENT PLAN OR ASSESSMENT (New item proposed)

Highly complex patient 75 years and over

Dis ea s e s pecific pla n i.e. a s thm a 3+ vis it pla n, dia betes pla nor m enta lhea lth pla n

M u ltidis ciplina ry Ca re Pla nor Ca s e Conference (exis ting )

Hea lth As s es s m ent

Complex patients

Review

Review

Review

40

Annu a lHea lth As s es s m ent

As Divisions move to embrace a role educating and supporting general practices (as opposed to general practitioners) within the health care system, this issue should be addressed. Almost all Divisions agreed that they saw their future role more clearly along these lines, i.e. helping practices reflect on their current practices in relation to quality and evidence based care and how to establish supportive systems both internally and to link them with other providers. Bringing GPs and allied health providers together often for training, case studies and patient management issues is desirable to break down negative stereotypes and preconceived ideas. Systems and models that facilitate collaboration with other service providers, for the variety of different practices that exist, need to be developed for dissemination to all practices. Practices need information, ideas and support to consider how they can work more closely with other providers to enhance the care of their patients with complex needs. Recommendation 7 Further strategies need to be developed to enhance the linkages between general practitioners, allied health professionals and other service providers. The measurement of the impact of the EPC MBS items and the GPESCL Program on quality of care was not possible in a systematic way in terms of health outcomes, however there were some indications of the broader impact that the introduction of the items may have had on quality of primary health care services by GPs and other health providers. Firstly, the time spent by GPs indicates that the opportunity for reflection, greater communication, negotiation and agreement on problems, issues and solutions that could be jointly implemented was a promising sign. Secondly, patient and GP interviews confirmed that patients gained access to new services through the health assessment or care plan process. Thirdly, most patients and some GPs reported that they were more confident since the care plan or health assessment had been done. They had many gaps in their records filled in and there was a document with all relevant information in one place, which they could send to others or carry with them. Overall, the introduction of the EPC MBS items has produced positive but limited improvements in quality in relation to primary medical care services by GPs. Although the quality has been highly variable, it can be concluded that the items have contributed to a shift in both the way GPs work and the types of services they provide to their patients with chronic illness and complex needs. There is currently some difficulty in GPs being able to access the evidence about quality care for people with chronic illness as it relates to the way they practice and their specific patients needs in an Australian primary health care context. The creation, documentation and dissemination of very practical models of service delivery to meet the needs of patients with chronic illness and complex care needs for Australian GPs are essential. The EPC items are being used in a wide variety of ways, many of which are innovative and have potential for wider utilisation. A program of operational research, perhaps linked to the Primary Health Care Research, Evaluation and Development (PHC_RED) initiative, would encourage the more formal development, evaluation and dissemination of models. The program could cover such aspects as integration with State funded community health programs, multidisciplinary care, incentives for engagement with the private health care sector, collaboration with

41

community nurses, systems approaches, nurses’ roles in general practice/primary care, economic models, and measuring outcomes of chronic disease management. Practice visits to explain models and opportunities for embracing new approaches, systems and structures are vital to the sustainability of the EPC strategy and the EPC MBS items in particular. Recommendation 8 The Department should resource a program of operational research aimed at developing, testing and disseminating models of effective management of patients with chronic conditions and complex care needs. There is also a need to ensure that GPs can collect data from their patient population and the services they provide using the EPC MBS items and integrate this with their other information management systems. There is a potentially rich source of data emerging through the use of the items, both for practices themselves and for the research community and policy makers. It is both about using EPC as a data source and about using IT systems to support the activity of GPs using the EPC items. Recommendation 9 The Department should ask the General Practice Computing Group (or other relevant body) to advise on how the data collection needs of the EPC services, including coding, can best be integrated with electronic medical records. There is also a need to embed in both undergraduate and postgraduate training, the approach to management of patients with complex needs through collaboration with other health care providers. Although this is a long term strategy, this systemic approach to encouraging and promoting collaboration for better quality patient care is fundamental to quality services and creating and sustaining a health care system that focuses on those patients who have the greatest needs, and whose risk factors are highest and who are most likely to suffer negative impacts from their chronic conditions. Recommendation 10 General Practice Education and Training Ltd. should be asked to ensure that GP training consortia curricula and training opportunities include a specific focus on the management of older patients and multidisciplinary management of those with chronic and complex conditions. Given the number of new MBS items created and new initiatives for management of chronic illness by general practitioners, it would be useful to take a broader view of the cumulative impact of all these strategies, as increasingly the individual effects will be harder to ascertain. Many of the recent initiatives – the EPC MBS items, chronic disease specific incentives, Sharing Health Care Initiative, Co-ordinated Care Trials and the various collaborative activities between State and Territory Governments, SBOs and Divisions at the State and regional level - aim to enhance the role and capacity of primary health care providers and consumers to maintain health, prevent illness and injury and generally improve quality and health outcomes. Any exploration of system and practice change would need to take account of the many drivers of change in existence. Recommendation 11 Any future review of the EPC MBS items should encompass their linkages with the more recently introduced chronic disease items, and the other key policy frameworks for older people and those with chronic illness.

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Contribution to Policy Priorities The EPC MBS items and the associated GPESCL Program have both contributed to the achievement of policy priorities in primary health care development since the end of 1999. The key areas where there has been a contribution are: • Access to some services increased for some people. • Rural consumers have not been disadvantaged. • Integration has been facilitated, but more work needs to be done. • There is some potential to promote GP role in care co-ordination. • Multidisciplinary care has been encouraged, but more needs to be done. • There is some access by Aboriginal and Torres Strait Islander people, but more could be achieved. • High and low socio-economic areas appear to have similar access to EPC services. Access to some services has increased as a result of the development of care plans and health assessments. However, some groups, particularly Aboriginal and Torres Strait Islander people have not featured highly amongst the recipients of these services. People living in rural and remote areas do not appear to have been provided with fewer services than their urban counterparts. The data shows they may be receiving as many if not more services through the EPC MBS items. Their access to allied health services may be less, although the introduction of the MAHS program appears to have been a positive influence in that regard. Integration with other providers has been facilitated, but there is still a significant amount of work to be done to see any major shift to greater integration. It is unlikely that the EPC MBS items alone will make a big difference. However the items have assisted in opening up some dialogue between GPs, Divisions and allied health providers and their organisations. The care planning and case conferencing items do have the potential to improve care coordination, however on their own, they will achieve very little. Evidence based models and facilitating strategies at the local level are needed to further promote the notion of co-ordinated care amongst GPs. Most patients that received multiple EPC services did so from the same GP, with 88% of all repeat EPC services rendered by the same GP, suggesting that a consistent and integrated delivery of EPC services is feasible. The employment of allied health providers by Divisions and practices is a first step toward developing multidisciplinary teams within practices. The practice nurse and MAHS initiatives are useful vehicles for encouraging this approach. The capacity of GPs to delegate some of the technical aspects of health assessments and care planning, for example collecting information, facilitating communication, checking test results, and some of the organisational work around case conferencing, to others in the practice is critical to encouraging a multidisciplinary approach to care. There is limited evidence through the evaluation about access and equity. Few Aboriginal and Torres Strait Islander people have received services through the EPC MBS items. Of the 225,353 health assessments done in the first two years of the program, 1933 (1%) were claimed via the specific Aboriginal or Torres Strait Islander Item numbers (704 and 706). There is no data available and very little anecdotal information to understand what level of services people from culturally and linguistically diverse backgrounds have received via the EPC MBS items. 43

Conclusion The EPC MBS items and the associated GPESCL Program have made a significant contribution to the approach of general practice to patients with chronic illness and complex care needs in Australia. Consumers have generally welcomed the initiative of their GP in proactively calling them in to have a comprehensive discussion and assessment of their health and needs and helping them to better plan management of their health. Practice and system changes are emerging as a result of the items becoming available and this trend is anticipated to continue over the next decade. GPs are now familiar with health assessments and have plans to continue their use within their practice, with most engaging skilled staff to assist them to manage this new activity within their current workloads. Care planning by GPs has been of variable quality, but GPs are now starting to recognise the appropriate use of the items for a smaller group of patients with multiple chronic conditions and complex care needs. Further reinforcement of this approach is desirable. Despite the low rate of understanding of multidisciplinary work by general practitioners, there have been some improvements in quality of care through better communication and more comprehensive approaches to information gathering and allied health and community services usage. The EPC MBS items have enabled key policy initiatives of the Commonwealth Government to be implemented in relation to access to appropriate care for older people, integration with other health providers, care co-ordination by GPs, multidisciplinary approaches to care, access and equity.

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References Council on the Ageing (2000) Submission to the Commonwealth of Australia Department of Health and Aged Care on the External Review of Consumer Outcomes of the Quality Use of Medicines Strategy in Australia. Council on the Ageing, Melbourne Elkan R. Kendrick D. Dewey M. Hewitt M. Robinson J. Blair M. Williams D. Brummell K. (2001) Effectiveness of home based support for older people: systematic review and meta-analysis. BMJ. 323(7315):719-25. Department of Health and Aged Care (2001) Enhanced Primary Care – Building Better Care. Commonwealth of Australia, Canberra. Royal Australian College of General Practitioners (2000a) Enhanced Primary Care: Standards and guidelines for the Enhanced Primary Care Medicare Benefits Schedule items. Commonwealth of Australia, Canberra. Royal Australian College of General Practitioners (2000b) EPC Items at a Glance. From the Enhanced Primary Care: Standards and guidelines for the Enhanced Primary Care Medicare Benefits Schedule items Kit. Commonwealth of Australia, Canberra. Wilkinson D. McElroy H. Beilby J. Mott K. Price K. Morey S. Best J. (2002a) Uptake of health assessments, care plans and case conferences by general practitioners through the Enhanced Primary Care program between November 1999 and October 2001. Australian Health Review 25(4):1-11. Wilkinson D. McElroy H. Beilby J. Mott K. Price K. Morey S. Best J. (2002b) Variation between Divisions of General Practice in the uptake of health assessments, care plans and case conferences through the Enhanced Primary Care program. Australian Health Review 25(6):119-127. Wilkinson D. McElroy H. Beilby J. Mott K. Price K. Morey S. Best J. (2002c) Characteristics of patients receiving health assessments, care plans or case conferences by general practitioners, as part of the Enhanced Primary Care program between November 1999 and October 2001. Australian Health Review 25(6):128-36. Wilkinson D. McElroy H. Beilby J. Mott K. Price K. Morey S. Best J. (2002d) Characteristics of general practitioners, that provided health assessments, care plans and case conferences,as part of the Enhanced Primary Care program between November 1999 and October 2001. Australian Health Review 25(6):137-44. Wilkinson D. McElroy H. Beilby J. Mott K. Price K. Morey S. Best J. (2002e) Variation in levels of uptake of Enhanced Primary Care item numbers between medical practices, within Divisions of General Practice and jurisdictions. Australian Health Review 25(6):145-9. Wilkinson D. McElroy H. Beilby J. Mott K. Price K. Morey S. Best J. (2002f) Variation in levels of uptake of Enhanced Primary Care item numbers between rural and urban settings, November 1999 to October 2001. Australian Health Review 25(6):150-7.

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Acronyms and Abbreviations ADGP AMA CME CoTA Division(s) DoHA EPC FTE GP GPESCL HIC MBS MAHS PCH_RED PIP NRA RACGP SBO SMR

Australian Divisions of General Practice Australian Medical Association Continuing Medical Education Council on the Ageing Division(s) of General Practice Department of Health and Ageing Enhanced Primary Care Full time equivalent General practitioner General Practice Education Support and Community Linkages Health Insurance Commission Medicare Benefits Schedule More Allied Health Services Primary Health Care Research, Evaluation and Development Practice Incentives Program Non-referred attendance Royal Australian College of General Practitioners State Based Organisation Standardised mortality ratio

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Appendix 1: Interviewees for the Evaluation of the GPESCL Program and EPC MBS Items Interviewees PRACTICE STAFF GPs Registrars Practice Nurses Practice Managers Receptionist Diabetes Coordinator EPC Coordinator SUBTOTAL ALLIED HEALTH STAFF Diabetes Educators RACF DONs/Principal carers Pharmacists Social Workers Psychologists Podiatrist Exercise physiologist Dietician Community nurses Clinical support nurse Palliative care nurse Aged care liaison nurse ACAT nurse Extended care CCT nurse ADHD Project Officer GP liaison Project Officers Home Assistance Team Leader School Principal SUBTOTAL DIVISION OF GENERAL PRACTICE STAFF EOs/CEOs/Senior Management EPC coordinators/officers Project/Program Staff (including nurses, diabetes educators, mental health program officers SUBTOTAL

TOTAL

Urban

Rural

TOTAL

23

26 2 9 9 6 1 1 54

49 2 17 17 9 1 1 96

5 2 3 2 2 1 1 1 2 1 1

1

6 4 4 2 2 1 1 2 3 1 1 1 1 1 1 1 2 1 1

11

25

36

3 5 6

6 5 14

9 10 20

14

25

39

67

104

171

8 8 3

42

1 2 1

1 1

1 1 1 1 1 2 1

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CONSUMER INTERVIEWS • 67 consumers interviewed by telephone • 31 males and 36 females interviewed • 49 consumers from Divisions of General Practice classified as rural and 18 consumers from rural Divisions of General Practice • 36 consumers interviewed had had a health assessment, 21 received a care plan, 4 had both a health assessment and a care plan and 6 interviewees did not provide sufficient information to determine whether they had a health assessment or care plan SUBMISSION ORGANISATIONS • The Pharmacy Guild of Australia • The Speech Pathology Association of Australia Ltd • Illawarra Division of General Practice • Australian Physiotherapy Association • Fremantle Regional Division of General Practice • Rockingham Kwinana Division of General Practice • Canning Division of General Practice • Adelaide North East Division of General Practice • Ipswich and West Moreton Division of General Practice • Canterbury Division of General Practice • 4 Divisions of General Practice that did not wish to be identified • Consumers’Health Forum • Royal Australian College of General Practitioners

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