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Caredevo
GPCCMP and Chronic Disease Management

One consultation that opens the door to everything your patient needs next

Your patient has type 2 diabetes, heart failure, CKD, a previous MI, and he smokes and drinks. You have 15 minutes. Caredevo turns that one consultation into a structured GPCCMP, chronic disease actions, allied health referrals, and a care plan that carries forward into the next three, six, and twelve months.

This is not about faster notes. This is about one consultation that actually builds ongoing care.

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Caredevo GPCCMP and chronic disease management consultation workflow for Australian GPs

The real problem

15 minutes. 7 active problems. Zero time for a care plan.

Other AI scribes give you a faster note. Caredevo gives you a care plan.

What opens up

GPCCMP. Referrals. Actions. Reviews. All from one consult.

One structured note becomes multiple services and a framework for continuity.

Continuity built in

Every review starts with a plan, not a blank page.

Goals carry forward. Referrals are tracked. Reviews start with a structured plan.

See it in action

One consultation. One note. Multiple chronic disease services.

Caredevo demo showing how one consultation becomes a structured GPCCMP, chronic disease management actions, allied health referrals, and an ongoing care plan.

The consultation that never gets finished

Jack has seven problems. You have time for two.

Jack is 61. He has type 2 diabetes, heart failure, stage 3 CKD, a previous MI, obesity, active smoking, and regular alcohol use. His family has a history of prostate cancer. He is already on the GPCCMP. His annual review is overdue. His cardiologist letter from three months ago was never actioned.

The consultation runs to 20 minutes. The GP reviews his blood results, adjusts one medication, and books a follow-up. The GPCCMP does not get updated. The smoking and alcohol goals are not documented. The nephrology flag is not raised. The cardiac rehab referral is not written.

This is not a failing. This is general practice with insufficient structure and insufficient time — and it happens every single day across the country.

What was not documented in that consultation

  • Updated GPCCMP with current problems and goals
  • SMART goals for diabetes, heart failure, CKD, and obesity
  • Smoking cessation plan and alcohol reduction goals documented
  • Cardiology review flag — post-MI management
  • Nephrology referral for CKD progression
  • Cardiac rehab referral
  • Prostate cancer family history flagged for PSA discussion
  • 3-month and 6-month review schedule

None of this is unreasonable. All of it is standard care. And all of it gets skipped when there is no structured tool to help.

What Caredevo generates for Jack

Eight problems. One consultation. Every one structured.

Caredevo breaks Jack's consultation into individual problems, each with a clear goal, structured tasks, and a referral — ready to paste into his GPCCMP.

Goal

Achieve HbA1c below 7.0% within 6 months. Maintain fasting glucose within target range. Prevent diabetes-related complications including retinopathy, neuropathy, and nephropathy.

Tasks

  • Review HbA1c, fasting glucose, and renal function every 3 months
  • Optimise diabetes medications in context of CKD — review metformin dose if eGFR drops below 45
  • Annual diabetic foot assessment — inspect, document, and refer to podiatrist
  • Annual retinal screening — refer to ophthalmologist or optometrist
  • Brief lifestyle intervention — low GI diet, reduced portion size, and incremental physical activity goals

Referral

Dietitian — diabetes-specific nutrition plan. Podiatrist — annual foot check. Ophthalmologist or optometrist — retinal screening.

Goal

Optimise heart failure medications. Reduce symptoms of dyspnoea and fatigue. Prevent hospitalisation and further cardiac decompensation.

Tasks

  • Review medications — ACEi/ARB, beta blocker, MRA, SGLT2i in context of CKD stage and eGFR
  • Monitor weight, fluid status, and functional symptoms at every review
  • Ensure echocardiogram is current and cardiologist review is booked
  • Refer to cardiac rehabilitation program — exercise capacity and education
  • Educate on daily weight monitoring and when to seek urgent review

Referral

Cardiologist — heart failure management and medication optimisation. Cardiac rehabilitation program — structured exercise and self-management education.

Goal

Slow CKD progression. Maintain eGFR stability. Prevent complications including anaemia, renal bone disease, hyperkalaemia, and metabolic acidosis.

Tasks

  • Monitor eGFR, urine ACR, electrolytes, and blood pressure every 3 months
  • Review and adjust nephrotoxic medications — NSAIDs, contrast agents, dose-adjusted antibiotics
  • Manage blood pressure to target below 130/80 mmHg
  • Check haemoglobin, phosphate, parathyroid hormone, and vitamin D annually
  • Educate on fluid intake, salt restriction, and avoiding self-prescribed NSAIDs

Referral

Nephrologist — CKD progression monitoring and management optimisation. Dietitian — CKD-specific dietary advice including protein, potassium, and phosphate intake.

Goal

Optimise secondary prevention. Reduce risk of recurrent cardiac event. Maintain antiplatelet and statin therapy as per current guidelines.

Tasks

  • Confirm ongoing antiplatelet therapy, high-intensity statin, and ACEi as per post-MI guidelines
  • Monitor lipid profile — target LDL-C below 1.8 mmol/L
  • Confirm cardiac rehabilitation completion or initiate referral if not yet completed
  • Review ECG and ensure cardiologist follow-up is current
  • Reinforce smoking cessation as highest-priority modifiable risk factor for recurrent MI

Referral

Cardiologist — post-MI secondary prevention review. Cardiac rehabilitation — if not yet completed or if ongoing structured support indicated.

Goal

Achieve 5–10% weight reduction over 6–12 months. Improve HbA1c, blood pressure, and cardiac load through sustained weight loss.

Tasks

  • Document current BMI and waist circumference at each review
  • Set achievable, patient-agreed weight reduction goals with defined review milestones
  • Refer to dietitian for structured weight management plan
  • Refer to exercise physiologist — safe exercise program in context of heart failure and CKD
  • Discuss pharmacotherapy options — GLP-1 receptor agonists in context of T2DM, cardiac and renal safety

Referral

Dietitian — weight management and metabolic optimisation. Exercise physiologist — tailored exercise program accounting for cardiac and renal limitations.

Goal

Achieve smoking cessation within 3 months. Reduce cardiovascular risk, CKD progression risk, and post-MI complication risk associated with ongoing tobacco use.

Tasks

  • Document pack-year history and current daily cigarette use
  • Provide brief cessation intervention — motivational interviewing, stages of change framework
  • Prescribe pharmacotherapy — varenicline first line, or NRT if contraindicated
  • Refer to Quitline (13 7848) for structured telephone support
  • Review at 1 month and 3 months for progress and pharmacotherapy adjustment

Referral

Quitline 13 7848 — telephone-based cessation program. Consider formal cessation counsellor referral for patients with high dependence or previous failed attempts.

Goal

Reduce alcohol intake to below NHMRC guidelines — no more than 10 standard drinks per week and no more than 4 on any single occasion. Assess for dependence.

Tasks

  • Complete AUDIT-C or full AUDIT screening to quantify use and identify dependence risk
  • Provide brief alcohol reduction intervention with written patient materials
  • Document agreed reduction goal — specific target reviewed at next appointment
  • Review liver function tests and monitor GGT as a surrogate marker of ongoing intake
  • Refer to alcohol and other drug service if AUDIT score indicates hazardous use or dependence features

Referral

AOD counsellor or ADIS service — if AUDIT score is above threshold. GP Mental Health referral — if co-occurring anxiety or depression contributing to alcohol use.

Goal

Informed shared decision-making regarding PSA screening. Document family history formally and establish a surveillance plan.

Tasks

  • Document family history in detail — relationship, age at diagnosis, bilateral disease, known BRCA status
  • Discuss the evidence for and against PSA screening — informed consent documented
  • If patient agrees, arrange baseline PSA and digital rectal examination
  • Refer to urology if PSA is elevated above age-adjusted threshold
  • Flag for repeat PSA discussion at next annual review regardless of baseline result

Referral

Urologist — if PSA above age-appropriate threshold or if first-degree relative with early-onset prostate cancer warrants formal risk stratification.

All content is structured and editable. Clinical judgement and final documentation remain the responsibility of the treating GP.

Why this keeps happening

Chronic disease patients need the most. General practice has the least time.

The problem is not skill. It is structure and time. Every GP knows what chronic disease patients need. The system just does not give them the time to deliver it.

No time for care planning in the room

A 15-minute consult is enough to review problems. It is not enough to build a structured GPCCMP, set SMART goals for three conditions, write allied health referrals, and plan the next six months of follow-up.

Patients with multiple diseases need more, get less

The more complex the patient — type 2 diabetes plus heart failure plus CKD plus previous MI plus smoking plus alcohol — the more structured care they need. But the busier the consultation, the less time there is to structure anything.

Continuity breaks down between reviews

Without a structured care plan in place, three-month and six-month reviews start from scratch. There is no shared thread between consultations. Goals drift. Referrals are forgotten. The patient falls through the gap.

The MBS opportunity goes unbilled

MBS item 965 for the initial Chronic Disease Management Plan and item 967 for the review are both available — but only if the documentation is structured. Without a tool that generates that structure in the room, the billing never happens and the patient never gets the services.

The cost of not structuring ongoing care

When care plans are not structured and updated, patients with multiple chronic conditions drift. HbA1c climbs. Blood pressure goes unreviewed. Referrals are delayed. The patient comes back six months later in a worse position — and the GP rebuilds context from scratch, again.

This is not a once-off. For GPs managing 200, 400, 600 patients with chronic disease, this plays out hundreds of times each year. The gap between what these patients need and what is actually documented is enormous — not because GPs are not capable, but because there is no structured tool that makes it fast enough to happen inside a consultation.

What gets missed most often

  • Updated GPCCMP after each review
  • SMART goals per condition
  • Allied health referral coordination
  • Specialist and surveillance referrals
  • Structured follow-up schedule

Caredevo vs other AI scribes

Other AI scribes help you finish today's note faster. Caredevo helps you build ongoing care.

Standard AI scribes were built to reduce typing. That is useful. But chronic disease patients need more than a faster note — they need structured care that carries forward across every review.

Capability
Standard AI scribe
Caredevo

Faster consultation notes

Faster referral letters

Structured GPCCMP content

SMART goals for each chronic condition

Allied health referral support

3, 6, 12-month review and follow-up actions

Continuity across multiple consultations

Standard AI scribes are built for one consultation. Caredevo is built for the patient relationship.

How Caredevo works

One consultation. One note. Multiple services. Ongoing care.

Caredevo does not replace your clinical judgement. It gives you the structure that makes comprehensive chronic disease care achievable inside a standard consultation — and carries it forward every time.

01

One consultation

Capture the consultation by recording, dictating, Smart Paste, or typing. Caredevo builds one structured consultation note.

02

GPCCMP and chronic disease actions

Generate problems, SMART goals, actions, lifestyle advice, referrals, and review planning for each chronic condition.

03

Multiple services open

Support allied health referrals, specialist reviews, surveillance flags, and follow-up actions from the same note.

04

Continuity across reviews

The structured plan becomes the foundation for the next 3, 6, and 12-month reviews. Goals carry forward. Gaps are visible.

What one consultation with Jack could generate

GPCCMP update

Updated problem list, SMART goals per condition, actions and review plan for type 2 diabetes, heart failure, CKD, previous MI, and obesity.

Allied health referrals

Cardiac rehab referral. Nephrology for CKD. Exercise physiologist for post-MI conditioning. Dietitian for diabetes and weight management.

Smoking, alcohol, and lifestyle goals

Smoking cessation plan structured. Alcohol reduction goals set. Brief intervention documented with follow-up actions.

Prostate cancer family history

Family history flagged. PSA discussion documented. Next surveillance step noted in the care plan.

3 and 6-month review schedule

Follow-up plan structured with goals to review, tasks to track, and next services to confirm.

MBS item 965 and 967

Item 965 for the initial Chronic Disease Management Plan and item 967 for the review — both structured and documented from the same consultation.

All content is structured and editable. You retain full clinical responsibility for final documentation and judgement.

Conditions supported

Built for the full range of chronic disease in Australian general practice

Caredevo supports structured GPCCMP content and chronic disease management actions for the conditions your patients most commonly present with — and the combinations that make care planning genuinely complex.

Type 2 DiabetesHypertensionObesityAsthmaCOPDCKDIHDChronic PainDyslipidaemiaOsteoarthritisHeart FailureAtrial Fibrillation
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Why the complex patient matters most

A patient with one chronic condition is manageable. A patient like Jack — type 2 diabetes, heart failure, CKD, previous MI, obesity, smoking, and alcohol — needs goals, actions, and referrals for every problem, plus coordinated follow-up across every review.

This is exactly the patient that gets the least structured care, because the consultation fills with immediate clinical tasks and there is no time left for the framework.

Caredevo is designed for this patient. The more complex the case, the more it delivers.

The more chronic conditions, the more structured care they need — and the more Caredevo can help structure from a single consultation.

Platform features

Everything built around ongoing chronic disease care

GPCCMP

GPCCMP and Chronic Disease Management

Generate structured GPCCMP content including problem lists, SMART goals, clinical actions, referrals, lifestyle advice, and review plans for type 2 diabetes, heart failure, CKD, IHD, obesity, COPD, chronic pain, and other long-term conditions.

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Caredevo GPCCMP and chronic disease management structured content for Australian GPs

Why GPs choose Caredevo for chronic disease management

Structured care. Less admin. More continuity.

  • GPCCMP content from the consultation. Not from memory after hours. Structured problems, goals, actions, and review plans generated from the same note.
  • One consult opens multiple services. Allied health referrals, specialist reviews, surveillance flags, and structured follow-up actions generated from the same consultation.
  • Continuity built across every review. The next 3-month review starts with a structured plan, not a blank page. Goals carry forward. Gaps are visible.
  • Complex patients get comprehensive care. Patients with four or five chronic conditions get structured care planning for every problem — not just the one that fills the consult.
  • Complex patients get every condition structured. Every chronic condition gets its own goals, actions, and referrals — not just the one that filled the consultation.
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Example structured output

Consultation

61-year-old male with T2DM, heart failure, CKD stage 3, previous MI, obesity, active smoking, alcohol use, and family history of prostate cancer

GPCCMP content

Problems, SMART goals, and clinical actions for all four conditions. Review schedule set.

Referrals generated

Cardiac rehab, nephrology, exercise physiologist, dietitian, and smoking cessation support

Follow-up schedule

3-month and 6-month review actions structured. Next consult starts with a plan already in place.

Caredevo is an assistant tool only. Final clinical judgement and documentation remain yours.

Ready to try it?

One consultation that actually builds ongoing care

Generate structured GPCCMP content, chronic disease management actions, allied health referrals, and follow-up plans from a single consultation — and carry them forward into every review.

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Frequently asked questions

Answers for GPs considering Caredevo for chronic disease management.

A GPCCMP requires structured problem lists, SMART goals, actions, referrals, lifestyle guidance, and review schedules for each chronic condition. For a patient with type 2 diabetes, heart failure, and CKD, that is three condition sets to document — each requiring its own goals, actions, and follow-up. Without a structured tool, GPs are doing this manually across multiple systems, which is unsustainable in a standard consultation.
Caredevo turns the consultation into one structured consultation note, then generates GPCCMP-ready content including problem lists, SMART goals, actions, referrals, lifestyle advice, and review planning for each chronic condition. This turns what used to take 30 to 45 minutes of after-hours admin into structured content from the same consultation.
Other AI scribes focus on one consultation: faster notes, faster referral letters, faster typing. Caredevo is built for ongoing care. One consultation generates a GPCCMP, chronic disease actions, referrals, and follow-up tasks. It opens multiple services and supports the next three, six, and twelve-month care cycle — not just today's note.
Yes. Caredevo is designed for exactly this. A patient with type 2 diabetes, heart failure, CKD, previous MI, obesity, and lifestyle risk factors can be structured across all conditions from one consultation — each with relevant goals, referrals, surveillance items, and follow-up actions. The more complex the patient, the more value Caredevo delivers.
Yes. Item 965 covers the creation of a Chronic Disease Management Plan and item 967 covers the review. Caredevo generates the structured content — problem lists, SMART goals, actions, and referrals — needed to support both items from a single consultation.
Yes. A single chronic disease consultation can generate a GPCCMP update, referrals to allied health, a structured follow-up plan, and a three-month review schedule — all from the same structured consultation note.
Caredevo supports structured documentation for diabetes, hypertension, obesity, asthma, COPD, CKD, IHD, chronic pain, osteoarthritis, dyslipidaemia, heart failure, atrial fibrillation, and other long-term conditions managed in Australian general practice.
Caredevo is designed with a local-first mindset. Identifiable patient data is not used to train models, and you remain in control of what you save, export, or paste into your EMR.
Yes. Caredevo is EMR-agnostic. You can copy and paste structured output into Best Practice, MedicalDirector, or any other system without waiting for deep integration.
Yes. Every section can be reviewed and adjusted before use. You retain full clinical responsibility for final documentation and clinical judgement.
Patients with chronic disease who receive structured care plans, clear goals, coordinated referrals, and consistent follow-up are more likely to remain with their GP long-term. Caredevo helps you deliver that level of structured ongoing care at scale.