Chronic disease management

Find links, resources and information about chronic disease management for health professionals

Patients with a chronic condition which has been or is likely to be present for six months or more are eligible for Chronic Disease Management (CDM) services on the Medicare Benefits Schedule. This enables a GP to plan and coordinate the healthcare needs of the patients through development of a GPMP. This includes ongoing care needs through multidisciplinary team members (TCA).

A practice nurse, Aboriginal and Torres Strait Islander health practitioner, Aboriginal health worker or other health professional may assist a GP with the chronic disease management items (such as GP Care Plan or a Team Care Arrangement), however the GP must review and confirm all assessments or arrangements and see the patient.

The Care Plan should include the following;

  • The patient’s health care needs.
  • Health problems and relevant conditions.
  • Management goals with which the patient agrees.
  • Actions to be taken by the patient.
  • Treatment and services the patient is likely to need.
  • Arrangements for providing this treatment and these services.
  • Arrangements to review the plan by a date specified in the plan.

Team Care Arrangements (TCA) are designed for patients who require care from at least three collaborating health or care providers, each of whom provides a different kind of treatment or service and at least one of whom is a medical practitioner.
Team members could include:

  • The allied health professionals to whom a GP can refer patients for Medicare-rebateable CDM allied health services (i.e. Aboriginal health workers; Aboriginal and Torres Strait Islander health practitioners; audiologists; chiropractors; diabetes educators; dietitians; exercise physiologists; mental health workers; occupational therapists; osteopaths; physiotherapists; podiatrists; psychologists; and speech pathologists;
  • and/or other allied health professionals such as asthma educators, orthoptists, orthotists or prosthetists;
  • and/or other health or care providers such as registered nurses, social workers, optometrists and pharmacists.

A nurse/practice nurse/Aboriginal and Torres Strait Islander health practitioner or Aboriginal health worker who is independently providing ongoing treatment or services to the patient can constitute one of the three team members. For example they would provide services that are;

  • not part of the general practice medical services provided by the GP
  • not under the supervision of the GP
  • different to the ongoing care provided by the other members of the team

Where a nurse/practice nurses provides services on behalf of the GP or under GP supervision and not as part of their own independent professional capacity they could not qualify as one of the three independent members of the team.

Man inhaling from asthma puffer

About the program

The PHN Health Needs Assessment 2015-16 identified chronic disease as a barrier to good health across the catchment. The PHN works with general practices, nurses, local Hospital and Health Services and allied health practitioners to deliver chronic disease management initiatives.

In particular we offer support around:

  • MBS primary care items: health assessments, care plans, team care arrangements, and chronic disease management item numbers.
  • Supporting practices to identify patients with chronic disease or associated risk factors early
  • Best practice guidelines and clinical support systems including creating disease registers within general practice settings
  • Quality Improvement activities that utilise the Pen CAT data extraction tool
  • Data cleansing, setting up and maintaining effective recall/reminder systems

If you would like to enquire about chronic disease support within your practice, please get in touch with the Practice Support Team.