Case conferencing is a care management approach to review and clarify goals of care and treatment plans.
Case conferences can be offered to palliative patients:
- Living at home
- Recently discharged from hospital; and
- Living in residential aged care.
To meet the requirements to claim Medicare rebates:
- Organising and coordinating a case conference
- Explain the nature of the conference to the patient; and
- Obtain and record the patient’s agreement to your participation in the conference; and
- Record the details of the teleconference (date, duration, names of participants) and all matters discussed by the team; and
- Put a copy of that record in the patient’s medical records; and
- Obtain and record the patient’s agreement to the conference taking place; and
- Offer the patient (and their carer if appropriate) a summary of the conference; and
- Provide this summary to other team members; and
- Discuss the outcomes with the patient (and their carer if appropriate).
- Participating in a case conference
- Explain the nature of the conference to the patient; and
- Obtain and record the patient’s agreement to your participation in the conference; and
- Record the details of the teleconference (date, duration, names of participants) and all matters discussed by the team; and
- Put a copy of that record in the patient’s medical records.
- Medicare Items
- Organising and coordinating
- Item 735: at least 15 and less than 20 minutes in duration
- Item 739: less than 40 minutes
- Item 743: at least 40 minutes in duration
- Participating in the case conference
- Item 747: at least 15 and less than 20 minutes in duration
- Item 750: at least 20 and less than 40 minutes in duration
- Item 758: at least 40 minutes in duration
- Participants must include yourself and at least two other providers:
- Medical Specialists: palliative care consultant, geriatrician
- Allied health professionals: pharmacist, social worker
- Home and community service providers: district nurse, domiciliary care
- Care organisers: “Meals on Wheels”
- In addition to the team, the patient’s informal or family carer and/or the patient should be included.
- Consider what information is needed to be prepared before the case conference
The PEPSI COLA aide memoire is a tool used to support you in carrying out assessments, promoting communication with the patient and providing a framework to consider patients’ holistic needs. More information can be found on the Gold Standards Framework website.
"PEPSI COLA" flags important topics that should be considered in planning.
- Physical: symptom control, regular and as needed medicines, compliance / de-prescribing, complementary therapies
- Emotional: understanding expectations, depression and adjustment, fears / security, relationships
- Personal: spiritual / religious beliefs, inner journey, quality of life, patient / carer agenda
- Social support: benefits / financial, care for carers, practical support
- Information / communication: within team, between professionals, to and from patient, to and from carers
- Control: choice, dignity, treatment options / management plan, advance directive, place of death
- Out of hours / emergency: continuity, provision of after-hours care to patients / carers, carer support, medical support, access to medicines and equipment
- Late: end-of-life / terminal care, ceasing non-urgent medicines, patient and family awareness, comfort measures, spiritual care, excessive secretions, agitation
- Afterwards: bereavement follow-up / others informed, family support, assessment / audit, support team
- For inquiries about eligibility, claiming, fees and rebates, call the Department of Human Services (Medicare):
- Patient enquiries Telephone: 132 011
- Provider enquiries Telephone: 132 150
- The explanatory notes and item descriptors for these items are in the Medicare Benefits Schedule (MBS) available on the mbsonline website.
- Further information can be found on the Department of Health’s Multidisciplinary case conferences page.
Page updated 22 May 2017