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GP Chronic Condition Management Plan (GPCCMP): Requirements, Eligibility and MBS Item 965 Explained

Reno Riandito
GP chronic condition management planGPCCMPMBS item 965chronic disease managementgeneral practice Australia

A practical guide for Australian GPs explaining GP Chronic Condition Management Plans (GPCCMP), patient eligibility, billing rules, allied health referrals and MBS item 965.

GP Chronic Condition Management Plan (GPCCMP): Requirements, Eligibility and MBS Item 965 Explained

GP Chronic Condition Management Plan (GPCCMP): Requirements, Eligibility and MBS Item 965 Explained

A GP Chronic Condition Management Plan (GPCCMP) is a structured care plan used in Australian general practice to coordinate care for patients living with chronic or long-term medical conditions.

These plans help organise treatment, establish health goals, coordinate referrals, and monitor progress over time.

A GPCCMP also enables patients to access Medicare-supported allied health services, while helping GPs manage complex chronic disease in a structured and proactive way.

For official policy details see:

Table of Contents

What Is a GP Chronic Condition Management Plan?

A GPCCMP documents a structured approach to long-term care.

It usually includes:

  • the patient’s chronic medical conditions
  • agreed treatment goals
  • management actions for the GP and the patient
  • referrals to allied health providers
  • review and follow-up arrangements

The plan supports continuity of care, ensuring treatment strategies are clearly documented and reviewed regularly.

Chronic disease care works best when management is structured, monitored and coordinated.

GPCCMPs form part of the broader chronic disease management framework in Australian general practice.

Patient Eligibility

Chronic or Terminal Medical Condition

Patients may be eligible if they have at least one chronic or terminal condition expected to last six months or longer.

Examples include:

  • diabetes
  • cardiovascular disease
  • chronic pain
  • COPD or asthma
  • arthritis
  • mental health conditions
  • obesity associated with chronic disease

There is no fixed list of eligible conditions.

Eligibility relies on clinical judgement.

Official eligibility criteria:

👉 Services Australia – Requirements for chronic condition management plan

Health Professional Eligibility

Usual Medical Practitioner

A GPCCMP is typically prepared by the patient’s usual medical practitioner.

This means the GP who provides most of the patient’s ongoing primary care.

Continuity improves:

  • monitoring of chronic conditions
  • medication management
  • coordination of referrals
  • follow-up planning

MyMedicare Patients

Patients registered under MyMedicare should normally receive chronic condition management services through their registered practice.

This supports:

  • continuity of care
  • better coordination
  • improved long-term outcomes

More information:

👉 https://www.health.gov.au/our-work/mymedicare

Preparing the GP Chronic Condition Management Plan

Preparing a GPCCMP typically involves:

  1. Assessing the patient’s chronic conditions
  2. Discussing management options with the patient
  3. Agreeing on realistic treatment goals
  4. Documenting management strategies
  5. Organising referrals
  6. Establishing review arrangements

The patient should be actively involved in developing the plan.

Shared decision-making improves adherence.

Core Elements of a GPCCMP

A typical plan includes:

  • list of chronic conditions
  • treatment goals
  • medications and investigations
  • lifestyle strategies
  • allied health referrals
  • patient responsibilities
  • review schedule

If you want to improve goal-setting within care plans, see:

👉 How to Write SMART Goals in Chronic Disease Management

Referrals to Allied Health Professionals

Patients with a GPCCMP may access Medicare-subsidised allied health services.

Common services include:

  • physiotherapy
  • exercise physiology
  • dietetics
  • podiatry
  • psychology
  • diabetes education

Patients can usually access up to five allied health visits per calendar year.

The referral must be written by the GP and should align with the management plan goals.

Reference:

👉 Services Australia - Allied Health and Other Primary Health Care Referrals for GP Chronic Condition Management Plans

GPCCMP Unlocks More Than Just Billing

Many clinicians associate GPCCMPs primarily with Medicare billing items.

But the real value lies in the care pathway they enable.

A structured chronic condition plan creates opportunities for:

  • multidisciplinary care
  • proactive disease monitoring
  • preventive interventions
  • coordinated treatment strategies

Access to Multidisciplinary Care

A GPCCMP allows coordination with:

  • physiotherapists
  • exercise physiologists
  • psychologists
  • dietitians
  • podiatrists
  • diabetes educators

Multidisciplinary care is essential for managing complex chronic disease.

Structured Follow-Up Reviews

The plan also creates a framework for ongoing clinical reviews, allowing the GP to:

  • monitor disease progression
  • adjust medications
  • review lifestyle interventions
  • track treatment outcomes

Related article:

👉 From Standard Consult to Chronic Care Review Using MBS Item 965 & 967

Preventive Care Opportunities

Chronic disease reviews often identify opportunities for additional preventive care such as:

  • cardiovascular risk assessment
  • weight management
  • smoking cessation
  • mental health review
  • vaccination updates

This shifts care from reactive medicine to preventive care.

Billing the GP Chronic Condition Management Plan

GPCCMP services are billed through the Medicare Benefits Schedule (MBS).

MBS Item 965 – GPCCMP Preparation

Item 965 applies when a GP prepares a GP Chronic Condition Management Plan.

Full item description:

👉 https://www9.health.gov.au/mbs/fullDisplay.cfm?type=item&q=965

MBS Item 967 – GPCCMP Review

Item 967 applies when reviewing an existing plan.

During the review the GP should:

  • assess progress toward treatment goals
  • update management strategies
  • review allied health input
  • adjust referrals if required

Quick Comparison

Item Purpose
965 Prepare GP Chronic Condition Management Plan
967 Review GPCCMP

These items support ongoing longitudinal care.

Why GPCCMPs Matter in General Practice

Chronic disease accounts for a large proportion of general practice workload.

Structured care plans help:

  • improve coordination of care
  • reduce fragmented treatment
  • support preventive strategies
  • enable multidisciplinary care

They allow GPs to deliver long-term proactive healthcare instead of episodic treatment.

You may also find this article helpful:

👉 Managing Chronic Disease as a Lifetime Project

Using AI to Create GP Chronic Condition Management Plans

Preparing detailed care plans can be time-consuming.

AI tools can assist by:

  • organising consultation notes
  • generating structured care plans
  • suggesting treatment goals
  • coordinating referrals
  • planning follow-up reviews

This allows clinicians to spend more time on clinical decision-making and patient interaction.

⬆️ Back to Table of Contents

Generate GP Chronic Condition Management Plans Faster

AI tools such as Caredevo can generate structured GPCCMPs directly from consultation notes.

👉 https://caredevo.com/register

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