General practice toolkit for chronic disease management
16 Sep 2025
New toolkit to support GPs in managing chronic conditions
South Western Sydney Primary Health Network (SWSPHN) has launched a Chronic Conditions Management (CCM) toolkit to help general practices care for patients with long-term health conditions more effectively.
The release follows recent government changes that expand chronic condition care planning. The new GP Chronic Conditions Management Plan (GPCCMP) replaces the old GP Management Plan (GPMP) and Team Care Arrangements (TCA). It comes with updated templates, referrals, MBS item numbers and equalised Medicare rebates, designed to make the system simpler and more consistent.
The new model encourages:
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Regular reviews of care plans
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Stronger communication between patients’ care teams
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Ongoing access to the right care for existing patients
Eligibility for a GPCCMP remains at the discretion of the treating GP, who works with the patient to decide if a multidisciplinary approach is needed.
The CCM toolkit, created by SWSPHN’s Clinical and Quality Improvement team, supports practices involved in the Quality Improvement in Primary Care (QIPC) program. It provides:
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Resources to identify patients eligible for care plans
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Guidance on quality improvement activities
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Practical tools such as checklists and tips
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An Allied Health Tracker to help patients monitor their five Medicare-subsidised allied health appointments each year.
The aim is to improve patient outcomes, reduce unnecessary hospitalisations, and support general practice in delivering continuous, coordinated care.
Source: Practice Pulse, 17 September 2025 (SWSPHN)
