5 Ways to Provide Comprehensive Care in General Practice
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Read article →Chronic Disease Management in General Practice
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:
- GPCCMP – Item 965 (Initial chronic condition management plan)
- GPCCMP – Item 967 (Review of the plan)
- Previous items 721, 723 and 732
- Structured chronic disease workflows
- Linking problems, goals and actions in care planning
- Coordinating allied health and preventive care
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.
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The GP’s Practical Guide to care plan for Parkinson
An Australian GP’s step-by-step guide to designing a care plan for parkinson: eligibility, MBS alignment, team care arrangements, palliative planning, and practical tools.
care plan for parkinsonprimary caregeneral practice
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chronic kidney disease stages iv: A Practical Pillar Guide for Australian GPs
An in-depth Australian GP guide to chronic kidney disease stages iv — clinical recognition, care planning, workflow optimisation, and technology support.
chronic kidney disease stages ivprimary caregeneral practice
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Dementia care plan: What Australian GPs Need to Know
An Australian GP’s guide to building a practical, Medicare-ready dementia care plan with workflows, tools, and clinical tips.
dementia care planprimary caregeneral practice
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understanding chronic disease management plans: What Australian GPs Need to Know
A practical pillar guide for Australian GPs on understanding chronic disease management plans — eligibility, documentation, workflows, and AI tools to streamline care.
understanding chronic disease management plansprimary caregeneral practice
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Chronic Disease: Definition, Risk Factors and Long-Term Management
Learn what chronic diseases are, why they matter in Australia, common risk factors, and how structured care planning helps patients manage long-term conditions.
chronic diseasechronic illnesschronic disease management
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Chronic Disease Management Plan: Complete Guide for Australian GPs
Learn how to create a compliant chronic disease management plan, maximise Medicare billing, and save time using structured AI tools built for Australian GPs.
chronic disease management planGPCCMPMedicare
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How AI Is Making GP Health Assessments Actually Doable
Use AI to turn 75+ and ATSI health assessments into structured clinical documentation without staying back after clinic.
health assessmenthealth assessment mbshealth assessment medicare
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Multimorbidity: Managing Patients with Multiple Chronic Diseases in General Practice
Learn how GPs manage multimorbidity using chronic disease management plans, coordinated care, and structured clinical workflows.
multimorbiditychronic disease managementGPCCMP
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Who Qualifies for a Chronic Disease Management Plan in Australia?
Learn who qualifies for a chronic disease management plan (GPCCMP), eligibility criteria, Medicare requirements, and how GPs determine suitability for chronic disease care plans.
chronic disease management planGPCCMPchronic disease plan
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How to Write SMART Goals in Chronic Disease Management
Learn how to write clear, measurable SMART goals for GPCCMP (Item 965) and reviews (Item 967). Improve compliance, patient engagement, and chronic disease outcomes.
SMART goalsGPCCMPItem 965
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If the Goal Is Not Achieved, Fix the System: Rethinking Chronic Disease Management in General Practice
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.
SMART goalsGPCCMPchronic disease management
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Managing Chronic Disease as a Lifetime Project
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.
chronic disease managementGPCCMPItem 965
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