New Chronic Disease Management Framework templates available
June 26, 2025
The Department of Health, Disability and Ageing (AGDOHA) has announced that major changes to the Medicare Benefits Scheme (MBS) framework for Chronic Disease Management in Primary Care will come into effect from 1 July 2025.
These changes primarily affect medical practitioners, however, allied health professionals providing MBS services should be aware of the changes to plan and referral requirements.
Transition arrangements will be in place for 2 years to ensure current patients do not lose access to services.
Communicare has created Care plan templates for you to import to assist your Communicare Administrator with setting up for this change.
What are the changes?
Key updates to the framework for managing chronic disease include:
- A new streamlined GP Chronic Condition Management Plan (GPCCMP) will replace the GP Management Plan (GPMP) and Team Care Arrangements (TCA) and their respective MBS items from 1 July 2025.
- Existing GP Management Plan and Team Care Arrangements will be valid for 2 years to ensure patients do not lose access to services during this transition period. From 1 July 2027, these patients will require a GPCCMP.
- The GPCCM will be available to patients with at least one medical condition that has been, or is likely to be, present for at least 6 months or is terminal.
- To support continuity of care, patients registered through MyMedicare will be required to access the GP chronic condition management plan and review items through the practice where they are registered. Other patients will be able to access the items through their usual GP.
- Patients will be eligible for the plan if their condition is managed by their GP or prescribed medical practitioner, whether or not multidisciplinary care is required.
- GPs and prescribed medical practitioners will refer patients with a GP chronic condition management plan to allied health services directly. The requirement to consult with at least two collaborating providers, as described under the current team care arrangements, will be removed.
- Practice nurses, Aboriginal and Torres Strait Islander health practitioners and Aboriginal health workers will be able to assist the GP or prescribed medical practitioner to prepare or review a GP chronic condition management plan.
- The current referral form for allied health services will no longer be required. Referrals will be in the form of referral letters, consistent with the arrangements for referrals to medical specialists.
- The full MBS item descriptor(s) and information on other changes to the MBS can be found on the MBS Online website.
Supporting the MBS Chronic Disease Management Arrangements in Communicare
To support you in this change, the following Communicare templates have been prepared for you to import into Communicare:
- GPCCMP Chronic Conditions Management Plan and Review (Adult) – template type: Care plan. [download here]
- GPCCMP Chronic Conditions Management Plan and Review (Child) – template type: Care plan. [download here]
- GPCCMP Referral Letter Allied Health – template type: Referral letter. [download here]
(When downloading, remember once you open in your browser, RH click on the screen and ‘save’ to your folder so that you can ‘import’ into Communicare)
The above have been prepared as a generic template for your Communicare Administrator to import into Communicare. Communicare Administrators are advised to consult with their local GPs to review and adapt these care plans as required.
You may decide to copy and update one or more of these templates to suit the requirements of your health service and your local GPs.
Once imported [via Tools>Communicare Templates> ↓import], please review your current templates and disable and enable templates where required ready for 1 July 2025.
Implementing the changes and new templates
Please work with your health service Communicare Administrator to complete the following activities to ensure a smooth transition to the new GP Chronic Condition Management Plans:
- Carefully review the information on the new Chronic Conditions Management framework and assess how it may impact your workflows [MBS Online – Upcoming changes to the MBS Chronic Disease Management Framework; CDM-Summary-of-changes.pdf]
- After importing the templates, review them with your clinicians and modify as required for your local workflows;
- Review your Care plan workflows with your clinicians;
- Review and update any local clinical items/qualifier or recalls linked to chronic conditions management and care plans;
- Carefully review the available information from Medicare;
- Review and update your MBS shortlist;
- Review and identify any local reports that may need updating;
- Disable any suspended Care plans.
Should you require any assistance with these activities, please raise a service desk ticket so that our Application Specialist can contact you to discuss scoping requirements and a professional services quote.
GPCCMP MBS items will be available in the latest MBS release in July 2025. We will notify you when the MBS update becomes available at the end of the month.
For all Communicare support queries, please submit a ticket to the Communicare Service Desk.