SWSPHN has developed a Chronic Conditions Management (CCM) toolkit which offers resources designed to support general practices in managing patients with chronic conditions more effectively.
In July the government introduced changes in how general practice can help patients manage their chronic conditions.
The existing model has been expanded to include all chronic conditions and is now known as Chronic Conditions Management (CCM). This new 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.
Proposed changes to Medicare Benefits Schedule (MBS) items for chronic conditions management aim to simplify, streamline and modernise the arrangements for healthcare professionals and patients while promoting continuity of care.
They also encourage the regular review of chronic conditions management plans, support communication between a patient’s multidisciplinary care team and ensure existing patients can continue to access the care they need.
Living with a chronic condition requires long-term management and general practice is well suited to assist people in managing their chronic condition while helping to prevent deterioration or development of other chronic conditions. This also reduces the risk of hospitalisation.
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.
The toolkit was developed by SWSPHN’s Clinical and Quality Improvement (CQI) team to assist practices participating in the quality improvement in primary care (QIPC) program. The QIPC program has three aims: to 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 focus areas often chosen by practices is identifying patients with a chronic condition who are potentially eligible for care plans and reviews.
SWSPHN’s Chronic Conditions Management toolkit (CCM) includes ideas, resources and useful information which can assist your practice in identifying and implementing chronic conditions management quality improvement activities.
The online resource includes sections on the foundation of quality improvement, quality improvement activities, tips and tricks and helpful resources.
There’s also an Allied Health Tracker for patients to record their visits to their Medicare-subsidised appointments with allied health providers. They are allowed five each year if they have a GPCCMP. The tracker enables them to plan ahead and make the most of the sessions they have left.
Access the Chronic Conditions Management Toolkit
Access the toolkitMy Chronic Condition Management Plan – Allied health visits tracker
Download here
This article appeared in Practice Pulse on Wednesday, 17 September 2025. If you are a GP, practice nurse or practice manager in South Western Sydney and do not get the weekly Practice Pulse email, speak to your Practice Support Officer.