Chronic disease is a growing problem and a leading cause of illness, disability and mortality. Chronic Conditions Management (CCM) MBS item changes recommended by the MBS Review Taskforce are the first major change to chronic disease management in 20 years and are scheduled to come into effect on 1 July 2025.
The changes aim to he changes aim to simplify, streamline, and modernise the arrangements for health care professionals and patients, promote continuity of care, encourage the regular review of chronic condition management plans, support communications between a patient’s multidisciplinary care team and ensure existing patients can continue to access the care they need.
To help general practices prepare, Murray PHN is releasing four activities between now and May, so information is more digestible and easier to implement.
Activity 1 – New year CCM resolutions
Many patients and practices time chronic disease management plans with the start of a calendar year, when allied health items are available through team care renew (items 10950 to 10970 and 81100 to 81125). The new year thereby provides an opportunity to complete the first steps in preparing for the upcoming CCM changes and not double up on work.
A range of ideas are outlined below – use, modify or develop your own plan for changes, documenting each activity using a Plan-Do-Study-Act Template ensuring responsibilities are allocated and timelines are included.
Activity ideas
Register all returning CDM patients for MyMedicare with your practice prior to, or at their next CDM appointment.
a. Prompt patients to register in advance of their appointments.
i. Send an SMS to all patients with a scheduled CDM encouraging them to register with your practice before their appointment using Medicare Online or print and complete a MyMedicare Registration form to bring to their appointment, or ii. Invite patients to attend their appointment early to complete a MyMedicare Registration Form in the waiting room.
b. Encourage patients to register at their next appointment.
i. Check each patients’ MyMedicare Registration status with your practice when they present for their appointment or the day before their appointment ii. Provide a MyMedicare Registration QR code or MyMedicare Registration form when patients present to the practice, and encourage them to complete their registration, or discuss registration as part of their CDM appointment iii. Have your practice nurse or Aboriginal Health Practitioner assist the patient with completing the registration for as part of their CDM appointment. This provides an opportunity for a conversation about expectations of an ongoing care relationship so that the practice can support the patient’s health journey in the long term.
Activity ideas
Review and strengthen your process for booking review appointments for any patient you put onto a Chronic Conditions Management Plan, or with an existing CDM Plan.
a. Consider and develop a method for how your practice will approach scheduling review appointments. You may decide to adopt a standard three-month review or six-month review approach or require the clinical team to advise on the review timelines informed by their clinical judgement on a case-by-case basis.
b. Develop workflows for reception – to ensure that as the patient is handed over to reception before they leave your practice reception has an action to schedule their next appointment, understands the timeframe for review to inform scheduling, and communicates the appointment time and date clearly to the patient (SMS, or reminder card, or other)
c. Develop a process for appointment reminders in leadup to review appointments – frequency (e.g. 1 week and 24 hours) and modality (phone call or SMS) to ensure your attendance rates for review appointments remain high. Include message for patient to check Medicare Online to ensure they are registered for MyMedicare with your practice, document any questions to bring to the appointment.
Activity ideas
Review and strengthen communication for why review appointments are important to attend for your practice team and patients (including if there are out of pocket costs for the patient).
a. Review your process and strengthen how you document priorities and actions due for the next review appointment in the patients’ medical record in your practice software as part of all CDM Plans and Reviews. For example, document any:
i. Outcomes, goals or targets the patient has for their review appointment ii. Education or points of discussion planned for the review appointment iii. Tests or pathology due that need to be scheduled iv. Referrals that need to be completed.
b. Communicate the importance of the review appointment with your patient and their carers (if appropriate) including:
i. Emphasise the importance of the review plan focusing on actions for the patient and why the review is needed with your patient at the conclusion of the appointment ii. Provide patient with a printed copy of the care plan and review appointment plan iii. Outline expectations and processes to re-schedule review appointment ahead of time.
c. Develop messaging for patients about the benefits of proactive care, care when you are not acutely unwell, or keeping you well. Develop communications to support this in your practice, for example:
i. Waiting room posters targeting CDM patients ii. Talking points for the practice team to reinforce the importance of reviews and attending for care when patients are not acutely unwell.
Activity ideas
Review and strengthen your process to manage missed or cancelled patient review appointments. Document the process for how to manage cancellations or missed review appointments. As part of this process consider:
a. How is the cancellation or non-attendance documented? For example, will your practice flag the patient, or retain a list of patients that need to be re-scheduled?
b. Who needs to be notified? (e.g. Nurse or Aboriginal Health Practitioner with responsibility for chronic disease coordination, and the patients usual GP)
c. What are the standing arrangements for re-scheduling CDM review appointments? For example, does your practice aim to re-schedule within two weeks of the cancellation or follow up non-attendance with a phone call to reschedule as a standard operating procedure?
d. Are there any data searches that need to be completed at regular intervals to identify any patients that may have missed their appointment but not been re-scheduled? For example, you could run a report from your clinical practice software for patients that have not had a review in more than six months and provide this list to a Nurse or Aboriginal Health Practitioner with responsibility for Chronic Disease coordination for review and action to check for any patients that have missed their scheduled review.
Activity 2 – Planning with your practice team
This activity aims to raise awareness among your practice team of MyMedicare, Chronic Conditions Management changes, and support your team to explore their roles in both MyMedicare and Chronic Conditions Management. By exploring and defining these roles, your practice team can work collaboratively to prepare for change and develop processes, systems and skills needed to succeed. This process will help ease your team through change and provide a shared document that can help your team to identify and discuss anything that isn’t quite working as planned, explore changes and update the document to keep everyone on the same page. This approach will allow your team to adapt and improve and empower each team member in their own role. There is a range of ideas outlined below for you to use to tailor and modify to develop your own plan for change at your practice. We recommend you document your plan using a Plan-Do-Study-Act Template.
Activity outcomes
Your practice team has a better understanding of MyMedicare (Voluntary Patient Registration)
Your practice team roles in MyMedicare and Chronic Conditions Management are well defined, and each team member has a clear role and responsibilities.
Activity ideas
a. Team meeting or quick lunch catch up to communicate the changes
b. Post an update in the practice staff room
c. Send an email to the practice team with the critical information
Activity ideas
a. Talking points for your practice for MyMedicare have been provided for you to adapt and share. If you plan to discuss these in an open forum with your team, you may want to share these in advance, and pose some general questions such as:
i. What could be some of the benefits of increasing MyMedicare participation for our practice?
ii. What does/could MyMedicare mean for our practice and patients?
iii. How does a stronger relationship with patients fit with our practice business plan and strategy?
b. The MyMedicare GP Toolkit provides a good summary of the current benefits of MyMedicare for general practices. The toolkit also includes a range of helpful resources your practice can use to communicate with patients.
Activity ideas
a. A summary of CCM changes has been developed for you to adapt and share. You may want to have a team discussion and pose some open questions such as:
i. How are these changes similar or different to current CDM care?
ii. Are our practice nurses or Aboriginal health practitioners confident in care planning or is there more training or development we wish to plan for?
iii. What is our ratio of care plans to care plan reviews at the moment? What changes would we need to make to conduct more regular reviews?
More considerations for planning are included in CCM Activity 1 (above).
A resource exploring practice roles and responsibilities for MyMedicare and Chronic Conditions Management has been developed and includes a blank template to help you get started (download Word document).
Activity ideas
a. Explore roles and responsibilities with the practice team in a meeting or quick lunchtime discussions
b. Document agreed roles and responsibilities and communicate this with your team
c. Discuss and document how each team member will incorporate their responsibilities into their workday and work week
d. Schedule a time to review your documented roles and responsibilities
i. Check in with your practice team four weeks after publishing these for a quick reflection and to maintain momentum as people adapt to their new responsibilities
ii. Review team roles and responsibilities at three months and make any changes or improvements based on lessons learned
Additional steps practices can take
Discuss what these changes mean with your team. Identify processes to review or update e.g. incorporate MyMedicare registration in your chronic disease management workflows.
Register your practice for MyMedicare if you have not done so already.
Encourage patients with a chronic condition or existing care plan to register with MyMedicare:
Murray PHN acknowledges its catchment crosses over many unceded First Nations Countries, following the Dhelkunya Yaluk (Healing River).
We pay our respects and give thanks to the Ancestors, Elders and Young people for their nurturing, protection and caregiving of these sacred lands and waterways, acknowledging their continuing cultural, spiritual and educational practices.
We are grateful for the sharing of Country and the renewal that Country gives us. We acknowledge and express our sorrow that this sharing has come at a personal, spiritual and cultural cost to the wellbeing of First Nations peoples. We commit to addressing the injustices of colonisation across our catchment, and to listening to the wisdom of First Nations communities who hold the knowledge to enable healing. We extend that respect to all Aboriginal and Torres Strait Islander peoples.
Leadership 
Collaboration 
Respect 
Accountability 
Innovation 
