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.