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).


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.