My Medicare toolkit highlights critical role of primary care nurses in chronic condition management
16 Sep 2025
The new approach follows recent reforms that strengthen continuity of care by linking patients to a single practice through MyMedicare registration. Registered patients can only access their General Practice Chronic Condition Management Plans (GPCCMPs) through their MyMedicare practice, while non-registered patients continue to access care plans through their usual general practice.
Primary care nurses play a central role in delivering and coordinating care under this model. Their responsibilities may include:
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Leadership and proactive care – prevention, screening, early intervention, follow-up after hospital discharge, and use of digital and remote monitoring tools.
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Sustaining patient-practice relationships – serving as a consistent point of contact for patients, even when GPs change, to ensure timely and appropriate care.
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Population health – managing patient registers, coordinating allied health, mental health and social supports, and encouraging patients to achieve care plan goals.
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Quality improvement – reviewing practice data, identifying gaps, and driving ongoing improvements in patient care.
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Central coordination and triage – managing access, scheduling case conferences, and ensuring regular reviews are completed.
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Brief intervention and coaching – supporting health literacy, self-management and social prescribing to keep patients connected and engaged.
Why MyMedicare matters
MyMedicare is a key part of the Strengthening Medicare reforms, aiming to reduce fragmentation, enable continuity, and create a stronger primary care system. Australia was one of the few OECD countries without a formal patient registration model, and this change provides the foundation for more consistent and comprehensive care.
Preparing for the future
SWSPHN encourages practices to:
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Embed MyMedicare into their culture and build long-term patient relationships.
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Track and monitor their MyMedicare patient cohort to provide comprehensive, coordinated care.
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Strengthen the role of primary care nurses as leaders in chronic condition management.
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Build skills in digital health, self-management support, motivational interviewing and social prescribing.
The MyMedicare Chronic Condition Management toolkit offers resources, checklists and guidance to help practices deliver these changes and ensure patients receive better coordinated, long-term care.
Source: Practice Pulse, 17 September 2025 (SWSPHN)
