MyMedicare Chronic Condition Management highlights the role of primary care nurses in supporting patients, reducing fragmentation, enabling continuity and strengthening the system.
MyMedicare registered patients can only access their General Practice Chronic Condition Management Plans (GPCCMP) from their MyMedicare practice. Patients not registered with MyMedicare can access GPCCMPs at their usual general practice.
The role of primary care nurses in GPCCMPs may include co-ordination and prioritisation of care, intervention and coaching, sustaining patient-practice relationships and quality improvement.
Why MyMedicare?
MyMedicare aims to reduce fragmentation, enable continuity and establish a system architecture for Strengthening Medicare. MyMedicare voluntary registration between a patient and a single general practice is a foundational building block of a high performing primary care system. Australians with primary care continuity have better health outcomes.
Prior to MyMedicare, Australia was one of three OECD countries without a primary care patient registration system, and there was no formal link between patients and general practices.
Strengthening Medicare reforms will continue to introduce measures to enhance continuity of care and enable practices to provide comprehensive care to their cohort of MyMedicare registered patients.
Practice nurse – role in Chronic Condition Management checklist
MyMedicare registered patients can only access General Practice Chronic Condition Management Plans exclusively from their MyMedicare practice. Patients not registered with MyMedicare can access GPCCMPs at their usual general practice.
The role of primary care nurses in GPCCMPs care may include:
- Leadership of MyMedicare enrolled patients – Greater focus on prevention and screening, proactive follow-up and data informed scheduling. Hospital avoidance strategies, coordination post hospital discharge, early and targeted and comprehensive lifestyle risk factor screening, remote and digital patient monitoring and virtual symptom monitoring.
- Sustaining patient-practice relationships and engagement – Build strong relationships as a primary contact for the patient in your practice. A role which withstands GP turnover, streamlining access for patients to more timely care with the most appropriate clinician in the practice team.
- Population health and managing registers of patients – Engage patients between GPCCMP reviews, identifying needs and solutions for social supports, giving feedback on patients who reach their management plan goals, identifying their next care steps, coordinating allied health, mental health and social supports.
- Quality Improvement – Review practice data to identify quality improvement opportunities for specific patient populations and coordinate quality improvement activities with the practice team. SWSPHN can support you with resources and programs to guide sustained quality improvement and lead change.
- Central coordination, triage and access prioritisation – Leading processes and system design for care coordination, processes for chronic care governance, triage and access prioritisation for patients with chronic conditions – guiding the practice with responses to higher acuity needs and a strong focus on access. Ensuring regular planned reviews are attended and missed reviews are rescheduled, facilitate and schedule case conferencing to involve the patient in choice and care ownership.
- Brief intervention/coaching – Improve health literacy and support self-management through health coaching and brief intervention. Connect patients with activities that maintain their health and social connection and support through social prescribing.
Actions – preparing for the future
Embed MyMedicare into your practice culture and enrol your patients
- Link MyMedicare with your customer/patient value proposition, focusing on ongoing relationships and comprehensive care.
- Create a trackable, traceable MyMedicare patient cohort which your practice will take increasing responsibility for into the future. Develop an engagement plan for your MyMedicare patients.
- Talk with your patients about the primacy of your general practice with them as their preferred practice for their care.
Strengthen your PN role
- Establish tasks supporting population health and coordinated clinical care.
- Explore this with your practice team and create systems and processes which enable you to perform this function and make patients aware of what they can expect from you as an important facilitator of care, and a central coordinator with their GP.
- Connect regularly with SWSPHN to stay aware of changes to primary care, and to access support to lead change and explore opportunities with your practice team.
Build skills
- Using technology to enhance care efficiency and patient engagement
- Delivering support for self-management, health literacy, motivational interviewing, social prescribing
- Create systems for tracking, tracing, monitoring, communicating with patients
- Quality Improvement and convening with the practice team to deliver comprehensive population health care delivery across your practice’s MyMedicare patient population
Learn more
The critical role of nursing in primary care – Karen Booth, APNA (Medicubes)
Principles of MyMedicare Chronic Condition Management – overview of key elements in chronic care planning
Transforming health care delivery – Robinson (2024), Australian Journal of Rural Health, on the role of primary health care nurses in rural and remote Australia
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.
