Upcoming Changes to Chronic Disease Management
From the 1st of July 2025, the Australian Government is introducing significant changes to the way chronic disease management (CDM) is structured and delivered. These changes aim to simplify and modernise care planning, based on recommendations from the Medicare Benefits Schedule (MBS) Review Taskforce and feedback from healthcare professionals.
At our clinic, we are committed to ensuring you receive the highest quality care under this new framework.
What Is Chronic Disease Management?
Chronic disease management is a structured approach to supporting patients with long-term health conditions — those that are expected to last at least six months or are ongoing by nature. These can include (but are not limited to) diabetes, heart disease, asthma, arthritis, chronic pain, and mental health conditions. The goal is to help patients manage their health effectively, prevent complications, and improve quality of life.
Under chronic disease management, a care plan is developed to outline your health needs and ensure you have access to appropriate services and support. These services may include not only your GP but also allied health practitioners such as:
- Physiotherapists (for mobility and pain management)
- Dietitians (for nutrition support)
- Podiatrists (for foot care)
- Psychologists (for mental health)
- Exercise physiologists (for tailored physical activity)
- Occupational therapists (for daily living and functional support)
- Speech pathologists (for communication and swallowing issues)
This team-based approach ensures that you receive coordinated, comprehensive care from the professionals best suited to support your condition.
The aim of chronic disease management is to empower you to take an active role in managing your condition, with your GP team working alongside you to keep your health on track.
What Are the Changes and Why?
The government’s review found opportunities to strengthen care plans and improve health outcomes for patients living with chronic conditions. One key finding was that many patients were not attending regular reviews, even though these reviews are essential for keeping care plans current and effective.
The new framework places a stronger emphasis on quarterly reviews (up to four per year). Regular check-ins help monitor your progress, identify any changes in your health, and ensure your plan is adjusted as needed.
Another important change is the introduction of MyMedicare registration, which ensures that your care is formally linked to our clinic, supporting better coordination and continuity of care.
The GP Chronic Condition Management Plan (GPCCMP) will replace the previous GP Management Plans and Team Care Arrangements. This change simplifies the process and supports a consistent, coordinated approach to managing your condition, ensuring you receive the best possible care.
The Role of MyMedicare
Under the new framework, MyMedicare registration plays an essential role in ensuring continuity of care. By registering with MyMedicare, your care is formally linked to our practice, supporting better coordination of your health services and ensuring that your chronic condition management plan is delivered consistently.
Through MyMedicare, you’ll continue to access a wide range of services and support that form part of your care plan — including allied health referrals, regular reviews, and enhanced communication between you and your GP team.
Our New Approach
To align with the national changes — and to provide even better support — our clinic will now encourage four CDM review visits per year, an increase from the one New Plan and one Review we previously performed each year. These reviews are designed to be streamlined and efficient, so they’re generally shorter unless adjustments to your plan are needed.
Your care plan will continue to be coordinated by our practice nurse, working closely with your GP. This ensures that your plan remains personalised and responsive to any changes in your health.
Additionally, we will be introducing video telehealth appointments where appropriate, making it even easier for you to stay on track with your care from the comfort of your own home.
As part of this process, we will be allocating a set number of allied health visits at each review. This ensures that we can monitor your progress effectively. If you have any questions about this, please ask our practice nurse, who will be happy to explain how this works.
What’s in It for You?
- More flexibility with referrals: Under the new system, referrals to allied health services can be addressed generically. That means you don’t need to know which particular provider you’ll see—you can take your referral to the provider that suits you best.
- Regular review opportunities: With up to four CDM reviews per year, you’ll have frequent chances to discuss your care, ask questions, and make sure everything is working well for you.
- Consistent, coordinated care: Your GP and our practice nurse will work as a team, so you can be confident that everyone is on the same page.
- Video telehealth options: Get the same quality of care from the comfort of your own home where suitable.
What You Need To Do
- Attend your CDM reviews — regular reviews are key to managing your condition effectively.
- Complete your MyMedicare registration — this helps us coordinate your care and ensures you get the most from your plan.
We’re excited to support you through these changes and help you manage your chronic condition with confidence. If you have any questions about your care plan, the new arrangements, or MyMedicare registration, please don’t hesitate to contact us.