This QIPC newsletter article outlines practical steps general practices can take to prepare for the changes to chronic disease management MBS items coming into effect from 1 July 2025. It includes a summary of the new items, the role of MyMedicare registration, and tips for updating workflows, improving data quality, and supporting continuity of care. It also highlights tools and resources available through SWSPHN’s QIPC program to help practices adapt smoothly.

Changes to chronic disease management aim to:

• simplify, streamline and modernise the arrangements for healthcare professionals and patients
• promote continuity of care
• encourage the regular review of chronic disease management plans
• support communication between a patient’s multidisciplinary care team
• ensure existing patients can continue to access the care they need

As part of the changes, the current GP management plans (GPMPs) and team care arrangements (TCAs) will be replaced with a single GP chronic condition management plan (GPCCMP). The existing MBS items for developing and reviewing GPMPs and TCAs will cease, and new MBS items for the GPCCMP will be introduced.

GPCCMPs are for patients with one or more chronic medical conditions who would benefit from a structured approach to their care. It is up to the GP’s clinical judgment to determine if their patient would benefit from a GPCCMP.

The changes will encourage regular chronic condition management plan reviews by equalising the fees for developing and reviewing GPCCMPs. The proposed new MBS item numbers are as follows:

More information about the upcoming changes to MBS Chronic Disease Management can be found at MBS Online.

Preparing for the proposed changes – MyMedicare registration

MyMedicare is a voluntary patient registration model available to all patients, practices and primary care providers who meet eligibility requirements. It aims to formalise the relationship between patients, their general practice, GP and primary care teams.

Why do we need MyMedicare registration?

Evidence shows seeing the same GP and healthcare team regularly leads to better health outcomes. MyMedicare registration enables a practice to access more information about their regular patients, making it easier to tailor services to fit the patient’s needs.

To support continuity of care for people with chronic and complex conditions, patients registered through MyMedicare will be required 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.

New telehealth items will be linked to MyMedicare registration, including:

• longer MBS-funded phone calls (Level C and D) with the patient’s usual practice
• triple bulk-billing incentives for longer MBS telehealth consultations (Levels C, D and E) for children under 16 years, pensioners and concession card holders.

Find out more – General Practice MyMedicare registration

Find out more – Patient MyMedicare registration

Find out more – Upcoming changes to the MBS Chronic Disease Management Framework

eLearning: MyMedicare – Health Professional Education Resources

To help your practice prepare for the transition to chronic conditions management (CCM), start by implementing small, manageable changes. Focus on raising awareness among your team about MyMedicare and the updates to CCM. Encourage your team to explore their roles in both MyMedicare and CCM.

QIPC and CCM

The SWSPHN Quality Improvement in Primary Care (QIPC) program has three main aims:

1. improve data quality
2. utilise practice data to improve patient care
3. identify potential business revenue for the practice

In line with these three aims, a quality improvement (QI) focus area often chosen by practices is identifying patients with a chronic disease who are potentially eligible for care plans.

In preparation for the proposed CCM changes, practices can ensure their current patients with a chronic disease are registered with MyMedicare. The SWSPHN Clinical and Quality Improvement (CQI) team has prepared resources to assist practices with this:

POLAR walkthrough– You can check how many of your patients with a chronic disease are registered/not registered for MyMedicare

MFI– A sample QI activity to register current chronic disease management patients with MyMedicare

Best Practice and MedicalDirector Clinical software guides – Where to document MyMedicare registration in the patient file to enable POLAR to pick up

Helpful tips for GPs, managers and nurses

Private bookmark:

The Private Bookmark Function in POLAR allows the user to save searches of specific patient cohorts by creating a bookmark. The user can create these bookmarks by clicking the tab at the top right-hand corner of the page.

Download Private Bookmark Walkthrough

Correct documentation:

For POLAR to obtain precise and reliable data, every item should be documented correctly in the patient’s file. To assist clinicians and practice staff in documenting care items in the appropriate location in their clinic’s medical software, data mapping is available via the Help menu.

Practice checklist

To help your practice get ready, we’ve put together a simple Practice Checklist you can utilise and ensure a smooth transition. It outlines some steps to align your current chronic disease management workflow with the updated MBS items and highlights practice actions your team can take now to stay ahead.

Preparing Your Practice for Chronic Condition Management Reform Checklist

To find out more about SWSPHN’s QIPC program, please email cqisupport@swsphn.com.au or visit our website Quality Improvement in Primary Care.

Resources for practices

MBS Online – Upcoming changes to the MBS Chronic Disease Management Framework

MyMedicare Program Guidelines

MyMedicare GP toolkit

Changes to chronic disease management MBS items begin 1 July