Changes to Chronic Disease Management Plans (Care Plans)

From 1 July 2025, Medicare introduced a new system for chronic disease management. The changes are designed to streamline your care, improve access to services, and support better coordination.

What’s Changed

• GP Management Plans (GPMPs) and Team Care Arrangements (TCAs) have been replaced by a single GP Chronic Condition Management Plan (CCMP).

• Patients with a long-term (6 months+) or terminal condition may be eligible.

• Referrals to allied health (physio, dietitian, podiatrist, psychologist, etc.) are now done by referral letter from your GP, not special forms.

• If you are registered with MyMedicare, your CCMP must be prepared and reviewed at your registered practice.

• There is a 2-year transition period - patients with existing plans will not lose access to services.

What This Means for You at Our Practice

• If you already had a care plan, we will gradually move you onto the new Chronic Condition Management Plan during the transition period.

• Your GP and practice nurse will work together with you to create and review your plan.

• During your nurse appointment, you will discuss your health and lifestyle, and set clear goals that are tailored to your needs.

• Your GP will finalise the plan, arrange any necessary tests, and make referrals to allied health providers if required.

• You will then have:

  • A review with your GP approximately every 3 months to update your plan, review results, and adjust your care where required.

  • Nurse support check-ins approximately every 3 months in between your review with your GP (often by phone, lasting around 10 minutes).

• To keep accessing allied health services, your plan must have been prepared or reviewed in the last 18 months.

Care Plans – How They Can Help

A GP Chronic Condition Management Plan can:

• Bring together your care in one clear plan.

• Set out health goals that you and your GP/nurse agree on.

• Help you understand your condition and be more involved in your care.

• Support you to manage your health day to day.

• Make sure important tests and follow-ups are not missed.

• Provide access to allied health professionals such as physiotherapists, dietitians, podiatrists, and psychologists.

• Encourage teamwork between your GP, nurse, and other health providers.

Who Might Benefit from a Care Plan?

People living with an ongoing or long-term condition may benefit from a care plan. These conditions can include (but are not limited to):

• Diabetes

• Heart disease or high blood pressure

• Asthma or lung conditions

• Cancer

• Stroke or recovery after stroke

• Osteoporosis or arthritis

• Mental health conditions

• Endometriosis

• Weight management concerns

• Autism spectrum disorder and other developmental conditions

Want to Know More?

• Please talk to your GP or our practice nurse at your next appointment.

• Visit our chronic disease management page: www.signalhealthnewton.com.au/chronic-condition-management

• Visit MBS Online: https://www.servicesaustralia.gov.au/requirements-for-chronic-condition-management-plan?context=20

Need a New Plan?

If you think it’s time for a new Chronic Condition Management Plan, or you are due for a review, please 📞 call us on 8360 9777 to discuss with your GP.