D2. Multidisciplinary care plans
Multidisciplinary care plans and individual self-management plans may help to prevent or manage crises (Lorig et al., 1999) [evidence level III-2]
A multidisciplinary care plan involves documentation of the various medical, paramedical and non-medical services required to keep a patient functioning in the community. Various generic and disease-specific proformas are available (see http://www.lungfoundation.com.au/professional-resources/general-practice/copd-action-plan for examples). The care plan may be initiated in the context of a multidisciplinary case conference involving the GP and at least two other health professionals (one of whom is not a doctor).
GPs are remunerated for their involvement in case conferences. This is supported by Extended Primary Care (EPC) item numbers, which vary according to the level of involvement of the GP and the location of the patient. The GP may participate by telephone. A consultant physician is also entitled to claim rebates for organising or participating in case conferences. Further information about item numbers is available at http://www.health.gov.au/mbsprimarycareitems
The multidisciplinary care plan may include a component of self-management with appropriate support.
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COPD-X Plan - Version 2.34 - November 2012