A practical guide for Australian GPs on GPCCMP (Item 965 initial, Item 967 review), previous items 721, 723 and 732, and structured chronic disease workflows.
Chronic disease care is a central part of modern Australian general practice. Conditions such as diabetes, cardiovascular disease, COPD and multimorbidity require coordinated long-term care across multiple providers.
Medicare has shifted chronic care planning from the traditional GP Management Plan (Item 721) and Team Care Arrangements (Item 723) framework to the newer GP Chronic Condition Management Plan (GPCCMP).
This hub brings together practical articles explaining:
The aim is to help GPs structure chronic disease consultations so documentation supports continuity of care, multidisciplinary coordination and Medicare compliance.
Below you’ll find guides covering chronic disease management and GPCCMP workflows in Australian general practice.
Latest
Learn who qualifies for a chronic disease management plan (GPCCMP), eligibility criteria, Medicare requirements, and how GPs determine suitability for chronic disease care plans.
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What are the key components of a senior care plan? A clear, practical guide for Australian GPs, practice owners, and families to turn consultations into structured, trackable actions.
A practical pillar guide for Australian GPs on understanding chronic disease management plans — eligibility, documentation, workflows, and AI tools to streamline care.
Learn how GPs manage multimorbidity using chronic disease management plans, coordinated care, and structured clinical workflows.
Chronic disease management is not a single plan but a lifelong project. Learn how to structure GPCCMP care using long-term thinking, measurable goals, and coordinated reviews.
When chronic disease goals are not achieved, the problem is rarely the goal itself. Learn why better systems, structured actions, and review processes matter more than rewriting targets.
Learn how to write clear, measurable SMART goals for GPCCMP (Item 965) and reviews (Item 967). Improve compliance, patient engagement, and chronic disease outcomes.
Use AI to turn 75+ and ATSI health assessments into structured clinical documentation without staying back after clinic.
An Australian GP’s guide to building a practical, Medicare-ready dementia care plan with workflows, tools, and clinical tips.
An Australian GP's guide to managing CKD Stage IV (eGFR 15–29): medication safety, complication screening, nephrology referral timing, GPCCMP documentation, and AI workflow tools.
Learn how to create a compliant chronic disease management plan, maximise Medicare billing, and save time using structured AI tools built for Australian GPs.
Learn what chronic diseases are, why they matter in Australia, common risk factors, and how structured care planning helps patients manage long-term conditions.
An Australian GP’s step-by-step guide to building a Parkinson’s disease care plan: MBS alignment, multidisciplinary team care, palliative planning, advance care, and practical AI tools.
A practical framework for Australian GPs to deliver comprehensive care across chronic disease, mental health, preventive care, screening, and lifestyle — structured as a system, not isolated consults.