Coordination of care for patients with chronic disease

The Team Care Arrangement system has room for improvement, but can aid effective patient care

Collaboration between health care professionals is recognised as a key strategy for effective care of patients with chronic disease.1 Multidisciplinary care planning involving general practitioners has been associated with improved outcomes for patients with chronic conditions.2 Care plans grew out of experience of the coordinated care trials, which aimed to optimise outcomes and resource use and were based on the principles of the Chronic Care Model.3 They were designed to coordinate care across multiple providers and involve patients in setting goals that can be achieved over 12 months, at least in part, by self-management. Subsequently, the Medicare arrangements were modified so that patients who had had both a GP Management Plan and a Team Care Arrangement (TCA) could access up to five visits to allied health professionals over 1 year under Medicare. These have been actively taken up by GPs and their patients. In 2008, there were 679 400 claims for Medicare Benefits Schedule item 723 (TCAs), at a cost of about $68 963 877.4