Section Three: General practice - systems and tools
Effective practice systems for patients in RACF
Using MBS items
Using Medical Director for residents’ care
GP Tools
The complexity of medical needs of residents, combined with their social context of dependency on relatives and residential care staff, presents a major challenge for the provision of 'round the clock' medical care.
As shown in Figure 3 (Section 2) the medical care process for RAC patients involves:
Comprehensive medical assessment. Goals of care, and Advance Care Planning. Medical management plans, and contribution to resident care plan. Referrals, and medical care coordination. Ongoing medical care (including patient consultations, additional services & liaison with relatives and other service providers).
Providing medical care for residents requires the use of effective practice systems and arrangements for working with several different RACFs as well as pharmacists, locum doctors and other service providers.
Effective strategies can be organised at several levels:
With individual patient, relatives and/or guardian: using Comprehensive Medical Assessment (CMA); case conferences, medical management planning, Advance Care Planning, clinical information sheets, etc. With RACF: by developing working arrangements with each RACF, which includes arrangements regarding contact person, communication, attendance times, case conferences, use of MBS items, after hours arrangements, medication reviews, reminders for patient reviews, GP involvement in advisory groups; or encouraging RACF to use the GP & Residential Aged Care Kit and Clinical Information Sheets; or by participating in the Aged Care GP Panel Initiative, etc. At the General Practice: through practice organisation, such as involvement of practice nurse, electronic templates (care plans), patient register and reminder systems, clinical audit, use of MBS items, and practice support from the local Division of General Practice, etc.
Organisational strategies and tools are listed in Table 1 (Section 2).
Clinical Information Sheets and Reference Cards in Section 5 cover medication management, Advance Care Planning, end-of-life care, and the management of specific conditions.
Other available clinical resources include the RACGP Medical Care of Older Persons in Residential Aged Care Facilities, the Australian Medicines Handbook Aged Care Drug Choice Companion, Therapeutic Guidelines, and Geriatrics At Your Fingertips.
Useful tools can also be found at the North East Valley Division of General Practice website at www.nevdgp.org.au/, including templates and tools for aged care and enhanced primary care; many are adapted for use in Medical Director.
This Section prrovides systems and tools for effective working arrangements with RACFs and other service providers, using MBS items to help organise and remunerate multidisciplinary service provision, and using Medical Director to help streamline practice systems.
The Medicare Benefits Schedule (MBS) lists the MBS item descriptions and Medicare rebates available for medical and other services provided to patients. In summary, Medicare rebates are available for people living in residential aged care facilities for the following GP services (as at November 2006):
GP consultations in RACF, Comprehensive Medical Assessment (CMA), Residential Medication Management Review (RMMR); Case Conferences; and GP contribution to the resident's care plan.
If the service is bulk billed, the GP is able to claim a bulk billing incentive for eligible patients.
Medicare rebates are also available for residents for:
Allied health and dental services provided to eligible residents, when referred by a GP; and
Consultant physician’s participation in case conferences conducted within a RACF.
Figure 3 shows how available MBS items support partnerships between service providers and relate to a resident's medical care. Use of these item numbers requires the GP to work closely with RACF staff and other service providers and to accurately record information in order to comply with the conditions set out in the Medicare Benefits Schedule. Discussion between the GP and RACF staff on roles will avoid confusion and duplication of work.
This Kit includes GP tools and RACF tools to simplify the process and paperwork for using and claiming MBS items.
Figure 3: How MBS Items relate to a resident’s medical care
GP consultations in RACF
The purpose of Medicare rebates for GP consultations at the RACF is to reimburse the GP for routine medical care, plus travel time. Medicare reimbursement per patient increases with the length/complexity of the consultation and decreases with the number of patients seen on the occasion of the GP visit to the facility.
However, the current rebate level may not adequately reimburse GPs for some elements that are an essential and substantial part of routine medical care of residents:
GP seeing multiple patients at a facility, to ensure good working arrangements can be developed with staff, Complex nature of care provided by the GP during time spent with patients who are often frail, cognitively impaired, and have multiple medical problems, and GP time spent providing patient care needed by residents, through:
Talking/consulting with RACF staff, relatives, pharmacist and other care providers. Arranging referrals. Writing clinical notes in both the resident’s RACF record and the patient record at the general practice. Regular review and rewriting of prescriptions and medication charts. Telephone advice, particularly after hours.
Comprehensive Medical Assessment
An up to date medical summary for patients, including those in residential care, is a general practice accreditation standard. Comprehensive medical assessment covers diagnostic evaluation and a problem list, as described in Section 2 of the Kit.
A CMA is available to new residents on admission into a RACF, but only if a CMA has not been undertaken for the patient in the previous 12 months. Existing residents can have a CMA where it is required in the opinion of the resident's general practitioner, eg a significant change in the resident's medical condition and/or physical and/or psychological function, but only if a CMA has not been undertaken for the resident in the previous 12 months.
A maximum of one Medicare rebate is payable for a CMA for a resident in any twelve month period.
The CMA complements normal aged care consultation items and other Medicare items such as case conferencing, contribution to a multidisciplinary care plan and residential medication management review.
CMAs enhance the quality of medical care provided to RACF residents by enabling the GP to undertake a comprehensive review of residents' medical conditions, identify their medical needs and provide important medical information, including diagnoses and problems.
Figure 4 is a flowchart of steps for doing a CMA.
Figure 4: Comprehensive Medical Assessment Flowchart
The information from a CMA can be used to:
Discuss goals of care and Advance Care Planning with the resident and relatives;
Assist the GP in planning medical management, including preventive care, treatment of chronic disease and geriatric syndromes, medication management, palliative and end of life care; Establish closer working relationships between the GP and RACF staff; Refer to the consultant pharmacist for a RMMR; Inform the GP contribution to the resident’s care plan (and subsequent referral for dental and allied health services, if required); and Provide medical information to RACF staff and other service providers, eg on referral for after hours and acute care.
GP tools include:
A number of different Comprehensive Medical Assessment forms to use for the CMA consultation with the resident, including:
Comprehensive Medical Assessment Step-by-Step guide, based on form developed by North East Valley Division of General Practice. An up to date paper version can be found at the following website: http://www.nevdgp.org.au/files/primarycaresupport/agedcareinitiative/Step%20by%20Step%20guides%20for%20GPs/Steps_%20for_%20GP_%20CMA_March%2006.doc Consent to Medical Care for Aged Care Home Resident Form, based on the form developed by North East Valley Division of General Practice, to assist GPs obtain consent to conduct a CMA. Medical Director has a CMA template built in, which can be accessed through LetterWriter, under Supplied Templates. The template is a copy of the CMA form developed by the Australian Divisions of General Practice (ADGP). The ADGP form can be accessed via the following website: www.adgp.com.au/site/index.cfm?display=2743
The RACF – Systems and Tools Section in this kit provides a checklist for RACF staff to use when considering a resident for a CMA.
Residential Medication Management Review
A Residential Medication Management Review (RMMR) is a collaborative service available to residents of a RACF who are likely to benefit from such a review. This includes residents for whom quality use of medicines may be an issue or who are at risk of medication misadventure because of a significant change in their condition or medication regimen. An RMMR provides an opportunity for GPs and pharmacists to assess medication-related information so as to identify and resolve any medication-related issues or needs. See the Clinical Information Sheet on Medication Management.
The RMMR Medicare rebate is available to permanent residents of RACFs receiving either high or low care. There is no age limit for a resident to be eligible for a CMA. Veterans in RACFs are eligible for CMAs.
A RMMR is available to new residents on admission into a RACF. Existing residents can have a RMMR on an `as required’ basis, where in the opinion of the resident’s medical practitioner, it is required, because of a significant change in medical condition or medication regimen. A maximum of one Medicare rebate is payable for a RMMR for a resident in any twelve month period, except where there has been significant change in medical condition or medication regimen requiring a new RMMR.
The RMMR complements normal aged care consultation items and other Medicare items such as Case Conferencing, contribution to a resident’s care plan, and Comprehensive Medical Assessment. Where a resident has a CMA, the RMMR should be undertaken preferably after the results of the CMA are available to inform the RMMR.
RMMRs can enhance the quality of medical care provided to residents of RACFs by optimising the therapeutic effectiveness and management of the residents’ medication regimens and minimising possible adverse effects.
Figure 5 is a flowchart of steps for doing a RMMR.
The information from a RMMR can be used to:
Assist the GP in developing or revising a medication management plan, Establish closer working relationships between the GP and accredited pharmacist, and Provide a medication management plan to resident and RACF staff.
GP tools include:
Figure 5: Residential Medication Management Review flowchart
Case Conferences
The purpose of Case Conference MBS items is to support multidisciplinary management of the health care needs of a patient with a chronic or terminal condition requiring complex care.
Eligible residents are those who suffer from at least 1 medical condition that has been, or is likely to be present for at least 6 months or is terminal, and requires care from the GP and at least 2 other formal health care providers. Refer to ‘Medicare Benefits Schedule Book – A.22 explanatory notes’ for more detail.
It is recommended that the resident and a relative be included in discussions, although they are not counted as participants for meeting requirements of the item numbers.
Service providers who, in addition to GPs, may be included in a multi-disciplinary Case Conference are:
Aboriginal Health Worker Audiologist Asthma Educators Dental Therapists Dieticians Diabetes Educators Mental Health Workers Occupational Therapists Optometrists |
Orthotists or prosthetists Personal Care Worker (Care Co-ordinator) Pharmacists Physiotherapist Podiatrists Psychologists Registered Nurses (Manager / Care Co-ordinator) Social Workers Speech Pathologists
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The Case Conference can be initiated and organised by either the GP or the RACF staff.
GPs can claim for a maximum of 5 case conferences per patient per 12 month period, either as the organiser or a participant.
GP tools include:
GP RACF Case Conference Record Template/Form, available in word or rtf format. Case Conference Step Chart to assist GPs to organise a case conference. Consent to Medical Care for Aged Care Home Resident Form, based on the form developed by North East Valley Division of General Practice, to assist GPs obtain consent to organise or participate in a case conference.
Case Conferencing can be set up in a number of ways to suit the working relationship between the RACF, GPs and other service provider/s. Examples of two different models for RACF staff to organise Case Conferences with GPs are included in Section 4, Residential Aged Care Facility - Systems and Tools.
RACF tools include a resident/relative letter and Case Conference Information Sheet. These could be adapted for use by the practice nurse if the GP is organising the Case Conference.
Case Conference MBS items (820-838) are also available for consultant physicians to organise or participate in community case conferences (including in case conferences conducted within a RACF). Refer to 'Medicare Benefits Schedule Book - A.25 explanatory notes' for more detail.
This provides GPs with the means of involving a private consultant physician in the timely care of a resident with a complex medical problem. Participation of the physician can be in person or by telephone, e.g. when the resident is unable to attend a physician due to distance (rural locations) or frailty. Examples of use of case conferencing with a GP, RACF staff and physician include problematic skin conditions (digital photos and referral letter can be emailed prior to discussion), and acute management of patients with advanced conditions such as cardiac failure, COPD or Parkinson’s disease.
GP contribution to a Resident’s Care Plan
Residential aged care facilities are required and funded to produce a care plan for every resident. The Resident’s Care Plan has a strong focus on personal and nursing care rather than medical care.
MBS Item 731 is for the GP to contribute to, or review, the Resident's Care Plan prepared by the RACF. It can be claimed 3 monthly intervals. A rebate will not be paid within three months of a previous claim for the same item, including if item 731 was claimed as a contribution to a care plan developed by a hospital from which the resident is being discharged. Refer to the 'Medicare Benefits Schedule Book - A.21 explanatory notes' for more detail
The GP contribution must be at the request of RACF staff. This should involve collaboration based on two-way communication (in person, by phone or in writing). The GP contribution should be documented in the Resident's Care Plan and a copy kept in the patient's medical record.
Contributing to the Resident's Care Plan provides an opportunity for the GP to view the plan and to add relevant medical care information, such as:
Information from the CMA, including medical diagnoses and problems, Medication management issues, Information from case conferences, Referrals needed for RMMR, allied health and dental services, and Arrangements and instructions for after hours and acute care.
GP tools include:
Referral to allied health and dental services
Where a resident's GP has contributed to a care plan and item 731 has been claimed, the resident is eligible to access certain Medicare rebated items for allied health and dental services on referral from their GP, where this is part of a multidisciplinary care plan for treatment of a chronic condition. These services can be provided at no cost to the resident if the service provider bulk bills (a small gap may be charged). Up to 5-allied health services per year in total (not 5 per service type) and 3 dental services are available. The allied health or dental service provider must be a private service registered with Medicare Australia.
Services eligible for the Medicare item numbers are:
Aboriginal Health Worker (10950) Audiologist (10952) Dietitian (10954) Mental Health Worker (10956) Occupational Therapist (10958) Physiotherapist (10960) Podiatrist (10962) or Chiropodist (10962) |
Chiropractor (10964) Osteopath - Osteopath (10966) Psychologist (10968) Speech Pathologist (10970) Dental Practitioner (10975) Diabetes Educator (10951) Exercise Physiologist (10953)
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All residents are eligible for the allied health and dental care rebates. However, high-care (as classified by the Resident Classification Scale) residents are only eligible for rebates if the service they are referred for is not already funded by the RACF. For example, the RACF funding usually covers a basic physiotherapy assessment, bot not ongoing treatment, which the allied health rebates could be used for.
The reference card Accessing MBS funded allied health & dental services for eligible patients provides an overview of the process for accessing the MBS funded allied health and dental care services.
Allied health referrals
To be eligible to access these rebates, residents need to have a chronic condition and complex care needs that are being managed by their GP and identified in the Resident’s Care Plan.
The GP refers the patient using an Enhanced Primary Care (EPC> Program referral form for allied health services. Where the GP is referring a patient to more than one allied health professional, he/she will need to use a separate EPC Program referral form for allied health services for each referral.The form can be ordered by calling (02) 6289 7120, or accessed via the Department of Health and Ageing Website at: www.health.gov.au/internet/wcms/publishing.nsf/content/strengthening+medicare-2
The process for accessing the MBS funded allied health services involves:
GP has contributed to the Resident's Care Plan and claimed MBS item 731. GP must use an EPC Program referral form for allied health services to refer patient. Eligible allied health professionals must be registered with Medicare Australia to provide services under this initiative. After the allied health service is provided, the allied health professional provides a written report to the referring GP. Maximum of 5 services per 12 month period.
Dental referrals
To be eligible to access these rebates, patients need to have a chronic condition and complex care needs that are being managed by their GP and identified in the Resident's Care Plan, and have a dental problem that is significantly adding to the seriousness of the chronic condition identified in the care plan.
GPs can only refer eligible patients to an eligible dentist, registered with Medicare Australia. GPs must use the EPC Program referral form for dental care services to refer to an eligible dentist.
There are three services provided under Medicare.
Item 10975: Dental assessment provided by an eligible dental practitioner
Item 10976: Dental treatment provided by an eligible dental practitioner
Item 10977: Dental service provided by an eligible dental practitioner or dental specialist
Patients are eligible for three dental services, however, the first must be a dental assessment (The assessment and first treatment can occur within the same dental consultation).
The process for accessing the MBS funded dental care services involves:
GP has contributed to the Resident's Care Plan and claimed MBS item 731. GP must use an EPC Program referral form for allied health services to refer patient. Dentists and Dental Specialists need to be registered with Medicare Australia. Dental practitioner undertakes dental assessment (MBS item 10975). Dental practitioner or dental specialist provides treatment/service. After the service, the providing dentist provides a written report to the referring GP, and referring dental practitioner if appropriate (if provided by a dental specialist). Maximum of 3 services per patient per 12 month period.
Using clinical computer software can help GPs plan prevention, disease management, medication management, and streamline the duplication of clinical notes at the general practice and in the resident’s RACF record. In the future, information technology will be used more widely for transfer of medical information between the GP, residential aged care facility and other service providers such as pharmacists and hospitals.
This Kit contains a guide to ‘Medical Director’ (MD), as it is currently the electronic record system most commonly used by GPs in Australia. Medical Director is also used at some RACFs as an aid to GPs providing medical care to residents. Instructions are for version 2 and version 3 of Medical Director. Screen dumps may display minor variations, depending on which version of Medical Director and Windows you are using.
The guide shows how to apply MD functions for the care of patients living in RACF. It includes:
Using the supplied templates for Comprehensive Medical Assessment (CMA), Residential Medication Management Review (RMMR) Plan and Referral, and Case Conference; Using the supplied forms for referral under the EPC Program referral for allied health and dental services; Importing and using the ‘GP RACF Case Conference Record’ template within this Kit; Printing ‘Compact’ medication chart labels (these are the medication charts most commonly used by RACFs in Australia), Establishing and using a patient register/recall/reminder system for RAC patients, and Using MD records on laptop at a RACF.
Other medical software companies may offer similar functions and information.
Medical Director has several templates suitable for use in RACFs, which are found in the “Supplied” templates. The templates available include:
Comprehensive Medical Assessment form; Residential Medication Management Review Referral form; Residential Medication Management Review Plan template; Case Conference template; EPC Program referral form for allied health services; and EPC Program referral form for dental services.
The example below is for the CMA, but the process for finding and filling out the templates are the same for all the templates listed above.
Using the Medical Director CMA
Open Medical Director and then open a patient file. Open LetterWriter by clicking on Tools menu, and then selecting LetterWriter from the drop down menu From the File menu select New and then click on the Supplied tab (see picture below).
Double click on the CMA Form. Fill out the form. You can use the 'Tab' key on the keyboard to quickly move down the form and then type or use an "x" to place a cross in the relevant boxes. Once the CMA is complete print and save in the usual way to preserve an electronic record in the patient’s record.
Setting up the template for use involves importing the GP RACF Case Conference Record template provided in this Kit into Medical Director, and adding RACF addresses to the Medical Director address book.
Completing a GP RACF Case Conference Record involves opening the template, which automatically includes GP and patient details, and then adding additional information required for clinical care and MBS item requirements. This section explains how to: enter patient information (e.g. allergies, past history etc.) into Medical Director, "populate" your template with this information, use some of the Letter Writer features of Medical Director to assist you to fill out additional information, and save and print the GP RACF Case Conference Record.
1. Import the template into Medical Director
The The GP RACF Case Conference Record template provided in the Kit can be imported from the Kit CD or the North West Melbourne Division of General Practice website. website.
Downloading the GP RACF Case Conference from the Web
Under NO circumstance should you open the template in WORD as this will destroy all the fields that are matched to the Medical Director database. The process for importing the GP RACF Case Conference Record template from the web involves:
Locate the GP RACF Case Conference template This is also available in the GP tools and reference cards section of the Kit Right click on the link to the GP RACF Case Conference template and select Save Target As... Select a location on the hard drive to save the template, such as the desktop (making it easier to find later). Save the template. Open Medical Director. Open LetterWriter by selecting the Tools menu and then select LetterWriter. From the File menu select Modify Template and then select Blank template. From the File menu select Import Locate the saved/downloaded file (on the desktop) and then click on Open. From the File menu select Save as template Type in appropriate name and Save.
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Downloading and installing from the CD
The process for importing the GP RACF Case Conference Record template from the CD involves:
Insert the CD into the disk drive. Open Medical Director. Open LetterWriter by selecting the Tools menu and then select LetterWriter. From the File menu select Modify Template and double click on Blank Template (see picture above). From File menu select Import. Navigate your way to the CD in your drive. In the folder named Downloads you will see a file called “GP RACF Case Conference Record”. Double click on it to open. This will place the GP RACF Case Conference Record template text into the Blank Template. Click on any of the <<field:fields>> to check that that they have imported correctly as fields. The field should turn grey, like this: <<Field:Field Name>> From the File menu select Save as template. Type in GP RACF Case Conference Record for the Template Name and then click on Save. Once again click once on one of the fields <<xxxxxx:yyyy>> and if it turns to a grey background then the field has successfully transferred across.
2. Add Residential Aged Care Facilities to the address book
The Residential Aged Care Facility details are taken from the Medical Director Address Book. You must ensure the Address Book is up-to-date with the details.
If "Residential Aged Care Facility" (or Aged Care Home) does not appear as a drop down option when selecting a category in the Address Book, you will need to set this up. To make Residential Aged Care Facility (or Aged Care Home) a category option, follow these steps:
Open any patient record. Go to the Tools menu and select Options. From Options select the Lists tab and click on the Address book categories button. Type in "Residential Aged Care Fac" (or "Aged Care Home" if you prefer). Click on the Add button. Click on the Save button.
When you return to the Address Book to add an entry, Residential Aged Care Fac (or Aged Care Home if you chose this title) will appear in the category drop down menu.
To add the details of a RACF to the Address Book, follow the following steps:
Open patient record. Click on the File menu and select Address Book (or click on the Address Book icon in the toolbar). In Medical Director version 2 click on the New Company button at the bottom of the screen.
In Medical Director version 3 click on New Entry and then click on the Company button. Type in the RACF address details, making sure to select "Residential Aged Care Fac" (or "Aged Care Home") from the Category drop down list. In Medical Director version 2, click on the Add button.
In Medical Director version 3, click on the OK button. Repeat the process for each Residential Aged Care Facility.
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Please note: Make sure that you do not type in the category but select "Residential Aged Care Fac" from the Category drop down list (see picture).
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3. Using the GP RACF Case Conference Record template
Completing a GP RACF Case Conference Record involves the following steps:
Before starting make sure the Medical Director Address Book is up-to-date with the details of the RACF.
Open patient’s record. Open LetterWriter by selecting the Tools menu and then select LetterWriter. From the File menu select New. The User Defined set of Medical Director templates is now displayed. Select the GP RACF Case Conference Record and click on OK. Select the appropriate RACF and click on OK. The address details will be added to the template. Fill out the User Defined Fields window when it appears (see picture below). You can press the 'Tab' key on the keyboard to jump to the next field. Click OK when complete. Proceed with filling in the rest of the form.
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Some other tips when using the GP RACF Case Conference Record in Medical Director include:
To fill in the checkboxes: highlight the checkbox and type an x. To highlight the checkbox: use the 'Tab' key on the keyboard to "jump" between fields and checkboxes. Highlight only the checkbox, not any surrounding area Make sure that you don’t use the 'Shift' or 'Caps Lock' keys If you make a mistake go to the Edit menu and select Undo
Medical Director (MD) now has the ability to enable GPs to print medication chart labels to allow easy updating and rewriting of drug charts for their patients in Residential Aged Care Facilities.
This kit describes how to print and use Compact medication chart labels, as most RACFs in Australia use the Compact medication charts and associated products, and MD software has the function built in to print Compact labels.
In order to take advantage of this tool, the GP needs to:
Ensure that the RACFs they attend have or are prepared to use Compact medication charts, Ensure that Medical Director has the latest list of your patients’ medications, and Obtain the medication chart labels from Compact.
Benefits of using computer generated medication labels:
Helps eliminate medication errors. Saves time in re-writing of medication charts. Caters to a wide range of medication categories including:
Short term drugs eg: Antibiotics. Long tem (regular) drugs (up to 6 months). PRN (when required) drugs.
There are 2 options that can be used when printing Compact medication labels for medication charts:
Printing medication chart labels
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1. Open a patient record
In MD2: From the menu at the top, click on Patient and select the required patient. - In MD3: Click on Open and select the required patient.
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2. Select Compact Business Systems.
In MD2: Click on Summaries, then click on Drug Sheets, and then click on Compact Business Systems In MD2: Click on Summaries, and then click on Compact Business Systems.
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A dialog box will appear with the patient’s current drugs.
The Compact medication chart has 3 main formats that allows you to print a Medication Label:
Short term drug orders (e.g. antibiotics); Regular drug orders; PRN drug orders;
Option 1 – Multiple medication labels
Once in the ‘Compact Business Systems Medication Chart’ dialog box, click on one of the drug categories (i.e. short term, regular, PRN) under Format (see picture right). Click on Use both sides of label sheet to print the required list (see picture right). To select the required medication in accordance with the Format medication categories (i.e. short term, regular, PRN):
Click appropriate squares to the left of each medication (see picture). If all medications belong to the same category, e.g. regular drugs, click Select All. To clear the entire selection click on Clear All
To print labels load printer with Compact Medical Director Labels and click Print.
You can only print medications from 1 format category at a time.
First time users may prefer to test print to an A4 sheet of paper, to do this click Print.
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IMPORTANT: Having printed the label, the GP should sign and date each medication in accordance with best practice (APAC) recommendations.
Label sheets are A4 in size to fit all printers (Ref: LTMCMD1). Medications 1 to 9 will print on the left label and medications 10 to 18 to the right label If there are only 9 medications or fewer, only the left label will print. The right label can be re used for another resident with 9 or less medications. To do so:
Each A4 sheet contains two labels that have been die cut for easy removal. These labels are to the exact size; when printed and adhered to chart, they completely overlay the medication order section.
Option 2 – Single medication label
Once in the ‘Compact Business Systems Medication Chart’ dialog box, click on one of the drug categories (i.e. short term, regular, PRN) under Format (see picture right). Under Label click the Single button. Select one medication by clicking on the box to the left of the required medication on the list. Click print and the ‘Single labels’ box will appear (see picture).
Ensure Label height is 30mm, Top Offset is 15mm. |
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Load printer with Compact Medical Director Label sheets.. These A4 label sheets contain 18 separate labels that can be used in sequence.) Select Row from 1 to 9, Select Column either 1 or 2, depending on the next available label on the sheet to be printed. Example:
1st label – Row 1 Column 1
2nd label – Row 1 Column 2
3rd Label – Row 2 Column 1
4th Label – Row 2 Column 2
Click OK to print label.
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IMPORTANT:Having printed the label, sign and date each medication in accordance with best practice (APAC) recommendations.
Label sheets are A4 in size to fit all printers (Ref: LTMCMD2). Each A4 sheet contains 18 labels that have been die cut for easy removal. These labels are to the exact size, and when printed and adhered to the medication chart, completely overlay the medication order section.
Using the medication labels
When printed the labels contain the following information:
Name and date of birth of resident Medication order category abbreviated as follows:
Short Term Order Regular Drug Order (REG) PRN Drug Order (PRN)
All medications selected with both brand and generic names Dose, route & frequency details
An example of a Regular Drug Order Medication Label is shown below.
To adhere labels to a medication chart:
Check resident name and date of birth to ensure correct chart; Check medication category printed on the label and turn to that section in the Medication Chart; Peel the label down a short distance and align the top of the label with the top of the Medication Chart page; Slowly remove the backing beneath the label while applying pressure to the front to secure it to the Medication Chart; Ensure alignment of medications with administration areas during this process.
It is important that the use of both label options conform to these instructions.
Do not attempt to use Option 1 labels for new medication or adjustments in between chart re-writes. Adding new medications to your database re-arranges the order of drugs on the list and subsequent print out.
The Aged Care Standards & Accreditation Agency will not accept the process of adhering one label over the other.
For further information on medication labels, contact Compact Business Systems on 1800 134 010 (Vic) or 1800 777 508 (all other states) or go to www.compact.com.au.
Establishing a patient register and recall/reminder system
Establishing a patient register/recall/reminder system for Residential Aged Care Facility patients involves using the customized fields to set up a register in the database, and then entering RACF patients into the register.
Using the register involves searching the database for RACF patients, and then saving, printing, and using the list for recall/reminder for resident review and appropriate action, or clinical audit purposes.
Create a RACF patient register - change customised fields
To set up a register of patients who are residents of Residential Aged Care Facilities, you need to set up Customised Fields in Medical Director. When changing customized fields, the change will be reflected in the whole program, i.e. the change will show in all patient files.
To set up Customised fields follow these steps:
Open the Medical Director program and at the initial Select patient from list screen, type in the first 3 letters of the patient surname, followed by a comma and then the first letter of the first name, eg. AND,M Double click on patient name and this will open that person’s record (see picture right).
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Once the patient’s record is open:
The Patient Details screen will display a series of tabbed headings. Click on Notes. In the lower half of this dialog box you will see a heading called Custom Fields. Click on the Set field names button and a new dialog box will appear.
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In Field 1 highlight and delete the Custom field 1 text. "Residential ACF" (or "Aged Care Home") (see picture right).
Note: If Custom field 1 has already been replaced by other text select Custom field 2 or Custom field 3. Click on the Save button and save.  Close the patient’s file by clicking on the Close this patient’s record button. When prompted to save a record of this visit click on No.
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How to enter patients into the RACF register
In the previous section you completed the set up of a RACF patient register. The register is now ready to accept patients that have been identified as residents of RACFs.
The following steps will need to be repeated for each patient that is a resident of a RACF.
To add patients to the RACF patient register complete the following steps:
Open an aged care resident patient record by typing in the first 3 letters of the patient surname, followed by a comma and then the first letter of the first name, eg. AND,D (for David Anderson). Click on the OK button and this will open that person’s record. Once the patient’s record is open:
The Patient Details screen will display a series of tabbed headings. Click on Notes.
Under Custom Fields you will see a field heading Residential ACF.Under this heading type “RACF” (or your choice of identification e.g. “Aged Care Home”) in the blank box (see picture right).
Note: Text in this field is not case sensitive.
Click on Save. Click on the Open next patient’s record button (or press <F2>) Or from the menu:
In MD2: Click on File menu, then Open Next Patient. In MD3: Click on Patient menu, then Open.
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When prompted to save a record of this visit click on No Select another patient that has been identified as a resident of an Residential Aged Care Facility and repeat steps 3-8 above. Repeat these steps for each patient that has been identified as a resident of a RACF.
Using the RACF patient register
To open the RACF patient register complete the following steps:
Without a patient record open:
In MD2: click on the Search menu and select Databases. In MD2: click on the Search menu and selectPatient The following dialogue box will appear (see picture below).
Under Residential ACF, type in RACF (or your choice of identification, "Aged Care Home"). Click on the Search button. Medical Director will display a list of Residential Aged Care Facility Patients with other relevant identifying information.
To save the RACF patient register complete the following steps:
When the RACF patient register is open, click on the Save button at the bottom of the screen (see picture right). When prompted for a 'File name' type in "RACF Register" and the date, e.g. "RACF Register 09-11-2003" (see picture right). Click on Save
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To print the RACF patient register complete the following steps:
When the RACF patient register is open, click on the Print button. A copy of the register will print.
The recall/reminder function is used to track when a CMA, RMMR, Case Conference, or contribution to a resident’s care plan is due.
A reminder for CMAs and RMMRs should be scheduled at 12 monthly intervals (see section above, which outlines the eligibility and MBS item requirements). Case Conferences are usually set at 6 monthly intervals, although it can be scheduled earlier if appropriate (a resident may receive MBS rebates for up to 5 Case Conferences per year). A contribution to care plan can be performed at 3 monthly intervals (see section above, which outlines the eligibility and MBS item requirements). The 5 MBS funded allied health services and 3 MBS funded dental services are available to residents every calendar year. These services can be referred to using the EPC referral form for allied health (or dental) services at any time of the year, but best done at the start of each calendar year (see section above, which outlines the eligibility and MBS item requirements).
All examples used within this section are for setting recalls for Case Conferences. The instructions can also be used to set recalls for CMAs, RMMRs, care plan contributions, and EPC referrals for allied health and dental services.
Medical Director will automatically update the recall date if the Case Conference record has been updated prior to the due date; this will be particularly useful if the GP and practice staff decide to coordinate/organise the Case Conference. (Remuneration for coordinating/organising is greater than participating in a Case Conference organised by the RACF.)
There are two ways to use the recall/reminder function:
You would most commonly use an "individual" recall which is generated while in the patient’s medical record, eg for Case Conference, routine (3 or 6 monthly) medication chart rewrites etc. Occasionally you may do a "bulk" recall when you call up all your Residential Aged Care Facility patients by using the Search database function and then adding a recall for all of the listed patients, e.g. you may use this method for annual flu vaccinations, for a clinical audit, or EPC referrals for allied health and dental services.
Before using the recall system you need to set up a Recall reason protocol that can be used for all patients you wish to review.
Setting the recall reason protocol
Open any patient record. From the Clinical menu select Recall. Click on the Add button. A new dialogue box will appear (see picture right). 4. Under the Reason for recall type in: GP RACF Case Conference (see picture right). Set the Interval to 6 months and click in the Once only recall box(see picture right). Click on the Save Protocol button; this Recall reason for call is now set for all patients. Click on the Cancel button. Click on Close.
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Recalling patients from the patient’s record
This method for recalling patients from the patient’s record should be used when a Patient record is open.
Open one of the patient’s records From the Clinical menu select Recall and the Recall items window is displayed.(see picture)
Click on the Add button. From the Recall list, select GP RACF Case Conference by clicking on it once. The Interval should already be set to 6 months (you set this protocol earlier). If it is a "one off" recall click on the Once only recall box. Click on Save.
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Bulk recalling of patients using the search database function
Practice staff will most likely use this method to recall all patients that have been recorded as RACF residents.
To perform a bulk recall using the search database function, complete the following steps:
Without a patient record open:
Under Residential Aged Care Facility, type in RACF (or your preferred choice of identification). Click on the Search button. Medical Director will display a list of RACF Patients with other relevant identifying information. Click on the Recall button. Under reason for recall click on GP RACF Case Conference and click on the Once only recall box. Click on the Save button; this will add a recall for ALL patients in the list, not just the highlighted patient. Click on the Close button.
Creating recall lists
The following search will create a list of patients that need a GP RACF Case Conference within the next 2 weeks (depending on the preferred interval selected) and provide enough patient details to allow the practice staff to co-ordinate and organise case conferences on behalf of the GP.
Close any patient record that may be showing; from the File menu select Close patient (or click on the Close this patient’s record button). From the Search menu select Recalls. In the Select Interval box select 2 weeks (see picture right). In the Select Reasons box select the GP RACF Case Conference, by clicking on it once (see picture right). Click on OK. A list of patients fitting the criteria will be displayed. Click on the Print button at the bottom of the screen; the list generated here can be used to coordinate and organise case conferences on behalf of the GP.
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If you don’t wish to include a patient in the printed list click on the patient’s name and then press the delete key on the keyboard.The dialogue box below will appear:
By clicking Yes you are able to remove the patient from the recall list as well as the list on the screen.
Using MD records on laptop at a RACF
Transfer patient data to laptop for use at a RACF
Patient records can easily and securely be transferred between Medical Director on the practice network and a laptop for reading, writing and printing from patient records at the Residential Aged Care Facility (RACF).
Setting up a laptop for use of MD at the Residential Aged Care Facility involves:
Installing MD on the laptop. Adding the RACF printer details (if needed). Connecting the laptop by cable to the network at the practice.
The laptop can be used as a stand alone at the RACF or be connected to the RACF printer for printing documents such as prescriptions, GP RACF CASE CONFERENCE RECORD, progress notes and pathology requests.
Using MD records on a laptop at the RACF involves downloading patient data to the laptop, using MD at the RACF, and uploading revised patient records at the practice.
MD on the laptop retains all features, including passwords for protecting patient confidentiality.
All patient data is stored securely at your practice, and is available when visiting patients at an RACF. This is achieved by temporarily copying data from the practice to a laptop to be used in the RACF. Medical Director will automatically merge the new data entered in medical records at the RACF with data held at the practice when the laptop is re-connected at the practice. Even if patient records are updated at the practice by another GP while data is held on the laptop, updated data on the laptop will still merge, and not overwrite, the data at the practice. However, simultaneous changes to demographic data may not be correctly updated.
<
p>Set up MD on laptop
Follow the instructions as per the Medical Director installation disk.
Download medical records to laptop
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Data from the practice server needs to be copied to the laptop. It is usually quicker to copy all data, rather than just the RACF patients. Copying all data allows patient data to be available for all patients, including those not previously categorised as RACF patients.
Close the Patient window, and remain in the Main menu From the Main Menu, select Tools, From the cascading menu select Manage Files, From the cascading menu select Download Files(see picture right).
This will instruct Medical Director to transfer patient data to your laptop. The next step is to instruct Medical Director to download selected patients or all patients.
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Use MD on laptop at RACF
At the RACF, open Medical Director, and the dialog box on the right will pop up. Select the option "Use these files". You will be presented with Medical Director screens for use. Connect computer to printer. Please note that the bottom of the Medical Director screen now displays "C\MDW2", instead of the practice file location, as highlighted under point 6 (red arrow and red circle) above.
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Upload medical records from laptop
When returning to the practice, connect your laptop to your network, start Medical Director, and the screen on the right will appear. This time, select the option "Reconnect to network". Medical Director will upload and merge records for those patients whose records you have altered. A dialog box labelled "Upload files" will display, together with a list of files being uploaded and the relevant patient names.
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When complete, you will be presented with your normal Medical Director screens. Please check that the bottom line of the Medical Director screen shows the location of the patient data the same as highlighted under point 6 (red arrow and red circle) above.
IT IS IMPERATIVE THAT AN "UPLOAD" IS CARRIED OUT AT THE PRACTICE AFTER CHANGING PATIENT DATA THAT OCCURRED AT THE RACF. IF YOU CARRY OUT ANOTHER "DOWNLOAD" FIRST, THEN ALL THE DATA FROM THE PREVIOUS RACF VISIT WILL BE LOST.
Connecting to printer at RACF
This involves two major steps. The first step is the installation of printer software onto your laptop, which typically will be completed by your IT support person, and is performed once only, per RACF.
The other step is described below, and involves the selection of the appropriate printer for use by Medical Director. Prior to altering Medical Director to utilise a different printer, physically connect the printer cable to the printer, as previously shown by your IT support person.
Select the main screen in Medical Director, select Tools
Select, Print Options
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The Print Options screen shows the printers that Medical Director is currently set up to use. Click on the "downward triangle" (in the rest of the document I have used "drop down menu – it depends what degree of consistency you want in the document) to the right of the Printer name to see the range of installed printers, and select the appropriate printer.
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The screen to the right shows multiple selections for the Script Printer. Select the appropriate printer, and change if appropriate, the Letter Printer, Pathology Printer and the Radiology Printer. Finally click on Save. The above processes need to be completed whenever a connection is made to a printer, different from the previously used printer.
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MD Mobility in Medical Director 3
MD3 has a special utility called “MD Mobility” which allows Practitioners to download their patient information and take it offsite (for example to perform Nursing home visits or hospital rounds). The patient information is copied to another computer and clinical information is then recorded, ready to be copied back to the surgery on your return.
MD Mobility in MD3 replaces the Upload/Download utility in Medical Director 2.
Installing MD Mobility
MD Mobility is not installed automatically when you install MD3. If you want to use MD Mobility on a given computer, you need to install it from the HCN CD. Once MD Mobility has been installed, it will be automatically updated (if required), each time you update MD3.
Full instructions
It is beyond the scope of this book to display the full instructions for installing and using MD Mobility. It is suggested you use the Help files in MD3. In the Search of MD Help type: mobility
It is also suggested that you enlist the support of your IT person to install MD Mobility and assist in the first downloads and uploads.
Reference Cards and GP Tools for Section Three
The following reference cards are designed to be used in conjunction with the information provided in Chapter 3 of the GP and RAC Kit. Because the evidence base and availability of national guidelines for clinical care and multidisciplinary service delivery is rapidly changing, we strongly recommend that the these Reference Cards be regularly reviewed and revised.
Viewing Reference Cards
To view the reference cards, click on the link and select open with.... The document will open in Microsoft Word (for .doc) or Adobe Acrobat for (.pdf).
Printing Reference Cards
To print the reference card, select follow the steps for viewing a reference card, then select print in either Microsoft Word or Adobe Acrobat.
Downloading Reference Cards
To download the reference cards, click on the link and select save to disk. You will be asked to select a folder in which to save the reference card. To download all the reference cards together, use the link under Downloads and Printing.
Reference Cards and GP Tools:
How to Access Allied Health & Dental Service - Medicare Rebates for Residents in Aged Care Facilities
Comprehensive Medical Assessment
GP Case Conference Record (.doc version)
GP Case Conference Record (.rtf version)
Comprehensive Medical Assessment (CMA) Item 712 Guide for GPs
Consent to Medical Care for Aged Care Home Resident Form.
Residential Medication Management Revivew (RMMR) Item 903 Guide for GPs
Case Conference Step Chart
Contribution to Care Plan Item 731 Guide for GPs
Download and Printing
See note on viewing and printing documents.
To download Section Three of GP and Residential Aged Care Facility Kit use the buttons below. Click on the link and select save to disk. You will be asked to select a folder in which to save the document. Downloads are in printable formats.
To print, download the document and use the options in Microsoft Word or Adobe Acrobat.
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