Chronic Disease Management (CDM) in General Practice involves early identification of chronic disease, appropriate primary and secondary prevention, and evidence based management. Nurse-Doctor teams have a key role to play in these areas of chronic disease in the community, as General Practice is usually the first point of contact in the health system.

PAT offers a number of innovations:

  1. It offers a work force solution based on the concept of the Patient-Nurse-Doctor team. The patient does about 40% of the questions in each clinic and their choices in these questions determine the treatment plan offered.
  2. It allows the option of converting the waiting room to a “virtual office” because patients can do their touch-screen responses there. This saves consulting room space.
  3. It saves doctor time by automatically generating a relevant GPMP. The only problems that appear in the plan are when the question answered by the doctor or patient requires ongoing management.
  4. Education is supplied in a small amount in each patient question. This enables the patient to understand both why the question is asked and to increase their understanding in short bursts.
  5. Evidence based medicine from the relevant guideline is similarly supplied in a small amount in each doctor question.
  6. A comprehensive algorithmic approach in the doctor questions ensures an easy use of guideline recommendations.

GP Management Plans (GPMPs)

A GP Management Plan (Item 721) may be completed by the patient’s usual GP for any chronic condition. A chronic condition is one that is likely to last 6 months or longer or is terminal. The minimum time to repeat the GPMP is 12 months unless the patient’s condition changes significantly.

Team Care Arrangements

A Team Care Arrangement (Item 723) can be completed after an Item 721 and this entitles the patient to 5 subsidised allied health visits in a 12-month period. PAT automatically generates the Team Care Arrangement (TCA) form for allied health refferals.

Annual cycles of care

  • An Asthma cycle of care may be completed for moderate to severe asthmatics once in a 12 month period (items 2546, 2552, 2558 which then trigger a SIP of $100).
  • A Diabetes cycle of care may be completed for all diabetics between 11 and 13 months each year (items 2517, 2521, 2525 which then trigger a SIP of $40).
  • Health Assessments such as the age 75 and 45 to 49 assessments for patients who are at risk of developing a chronic disease (items 701, 703, 705, 707).

The PAT tool will greatly assist with these areas and item numbers, and consists of 3 main sections:

1. Patient section

Patients, either with the aid of a nurse, answer a questionnaire on a touch-screen device and get interactive education based on their answers. The education includes motivational interviewing for smoking, losing weight & exercising. Answers to specific questions are used by the software to customise the Management Plan.


2. Nurse section

The Nurse Section is a checklist of tasks needed to be performed before the patient sees the doctor. Added to the patient section answers it provides the doctor with a comprehensive starting point.


3. Doctor section

The doctor completes a number of questions that include relevant pathology results, data entered by the nurse and links to evidence-based guidelines. A management plan is incrementally generated semi-automatically and edited to suit the person. The management plan combines relevant data entered by the patient and doctor.