Chronic Conditions Management Toolkit

Overview

The Australian Institute of Health and Welfare (AIHW) places chronic conditions as the leading cause of illness, disability, and death in Australia. Some chronic conditions are not preventable as they are genetic or the cause is not known (e.g. multiple sclerosis, type 1 diabetes, cystic fibrosis). Other chronic conditions can develop due to controllable or preventable risk factors (e.g. type 2 diabetes, kidney disease, and stroke).  

Living with a chronic condition requires long-term management. General practice is well suited to assist people in managing their chronic condition(s) and help prevent deterioration or development of other chronic conditions, and reduce the risk of hospitalisation. 

From the 1st of July 2025, the Australian government introduced changes in how general practice can help their patients manage their chronic conditions. The existing chronic disease management model has been expanded to include all chronic conditions and is now known as chronic conditions management (CCM). The new CCM model includes an updated streamlined management plan called the GP chronic conditions management plan (GPCCMP). The GPCCMP replaces the previous GP management plan (GPMP) and team care arrangements (TCA), with new care plan templates and referrals, MBS item numbers, and equalised Medicare rebates. 

Eligibility for a GPCCMP is at the discretion of the treating GP who, in collaboration with the patient, determines whether the patient would benefit from a multidisciplinary care approach to managing their chronic condition(s).  

To support continuity of care for people with chronic and complex conditions, patients registered through MyMedicare will need to access the GPCCMP and review items through the practice where they are registered. Patients who are not registered in MyMedicare may still access the services through their usual GP.  

The SWSPHN Quality Improvement in Primary Care (QIPC) program has three main aims – improve data quality, utilise practice data to improve patient care, and identify potential business revenue for the practice. In line with these three aims, one of the quality improvement (QI) focus areas often chosen by practices is identifying patients with a chronic condition who are potentially eligible for care plans and reviews. 

In this toolkit, you will find ideas, resources, and information that can assist your practice in identifying and implementing chronic conditions management quality improvement activities. To start you off you can use this preparing your practice checklist