Chronic Conditions Management – Change Activities for Your General Practice

Starting 1 July 2025, significant changes to Chronic Conditions Management (CCM) MBS items are set to take effect, marking the first major update in 20 years. To help practices transition smoothly, the Central and Eastern Sydney PHN (CESPHN) is launching a CCM activation series. This series encourages small, manageable changes and aims to strengthen patient connections through MyMedicare.

The changes aim to simplify, streamline, and modernise the arrangements for health care professionals and patients, promote continuity of care, encourage the regular review of CCM plans, support communication between a patient’s multidisciplinary care team and ensure existing patients can continue to access the care they need.

To help your practice prepare to transition to CCM with small manageable changes, CESPHN invites your practice to participate in our CCM activities to implement new CCM items, strengthening the connections that patients have with your practice through MyMedicare.

• Activity 1 aims to engage patients returning to your practice for CCM Plans and team care arrangements in MyMedicare.
• Activity 2 aims to raise awareness among your practice team of MyMedicare, CCM changes, and support your team to explore their roles in both MyMedicare and CCM.
• Activity 3 – coming soon 

Activity 1 Ideas: Encouraging MyMedicare Registration

• Send an SMS to patients with a scheduled CCM Plan, encouraging them to register before their appointment via Medicare Online or by bringing a completed MyMedicare registration form.
• Invite patients to arrive early to complete a MyMedicare registration form in the waiting room.
• Check each patient’s MyMedicare registration status before their appointment.
• Provide a QR code or paper registration form at reception to facilitate patient registration.
• Discuss registration during CCM appointments and encourage completion.
• Have Practice Nurses or Aboriginal Health Practitioners assist patients with registration, fostering discussions on ongoing care.
• Prompt patients to register in advance and encourage registration at their next appointment.

Activity 2: Strengthening Review Appointment Booking Processes

• Establish a method for scheduling review appointments (e.g., standard 3-month or 6-month reviews or clinical team recommendations).
• Develop reception workflows to ensure patients book follow-up reviews before leaving the practice.
• Create a reminder system (e.g., SMS or phone calls) at 1 week and 24 hours before the review appointment.

Include reminders for patients to check Medicare Online for their registration status and prepare questions for the appointment

Overview of MyMedicare and Chronic Conditions Management Changes (2025)

• MyMedicare is a key part of planned changes to Chronic Disease Management, subject to legislation.
• CCM MBS item changes are the first major update in 20 years, scheduled for 1 July 2025 (previously set for 1 November 2024).
• Additional time allows GPs, allied health providers, and practices to prepare.
• New CCM items will leverage MyMedicare, encouraging patient registrations.
• Patients registered with MyMedicare will need to access chronic condition management plans and reviews through their registered practice.

Preparation for Changes
CESPHN will support general practices to:

• Register for MyMedicare.
• Communicate with and register patients.
• Review workflows and team roles to enable more frequent patient reviews.
• Enhance confidence and capability of Practice Nurses and Aboriginal & Torres Strait Islander Health Practitioners in CCM plans and reviews.
• Utilise data for quality improvement activities related to CCM.

Impact from 1 July 2025

• Existing chronic disease management items will cease from 30 June 2025.

New CCM model aims to:

• Encourage regular reviews and continuity of care.
• Equalise MBS fees for CCM planning and review items.
• Strengthen the role of practice nurses & health practitioners.
• Streamline referrals & communication with multidisciplinary teams and allied health providers.

Resources

• CCM-Preparedness-Practice-Checklist_BNPHN.docx
• (Template) Practice roles and responsibilities for MyMedicare and CCM MyMedicare-Practice-Roles-and-Responsibilities-for-MyMedicare-and-Chronic-Condition-Management.docx
• Activity 3 Slide pack in now available Click here

If you require support for your practice on MyMedicare or the GP in Aged Care Incentive, please contact: 

• practicesupport@cesphn.com.au or 
• digitalhealth@cesphn.com.au