From 1 July 2025, a new framework for Chronic Disease Management was introduced by the Australian Government, based on recommendations from the MBS Review Taskforce. It is designed to streamline care planning, reduce administrative burden, and strengthen continuity of care.
The updated framework is known as Chronic Condition Management (CCM).
Healthy North Coast has been working with other PHNs nationally through the PHN Cooperative, the National Improvement Network Collaborative (NINCo), and the National MyMedicare PHN Implementation Program to develop the below helpful resources:
1. Chronic Conditions Management MBS user guide
The CCM MBS user guide aims to provide a practical and easy reference for general practices, demonstrating how to plan their delivery of care for their patients with chronic conditions.
2. Chronic Conditions Management QI workbook
The CCM QI workbook is a simplified and practical guide for implementing CCM through continuous QI activities.
It focuses on enhancing continuity of care, improving patient outcomes, and increasing practice efficiency by shifting from volume-based care towards structured, regular care planning and preventative care model. It recognises that this is a substantial behaviour change for patients and practices, requiring a change in perspective, models, systems, and attitudes toward care.
The CCM QI workbook links to existing resources related to MyMedicare and CCM. This QI workbook seeks to enable general practice to determine readiness for participation in the CCM, complete the registration process (if needed) and sets out actionable steps to improve your practice’s model of care for people with a chronic condition.
The CCM QI workbook is in Word format, so you can extract and edit details and/or select specific QI activities to participate in, as best for your practice. The workbook provides suggestions and ideas for improvement but is not prescriptive.
In summary, you will find information and guidance on:
- Checklist to prepare and implement CCM changes
- CCM and MyMedicare foundations
- Delivering care to meet MBS requirements
- QI and PDSA ideas
- CCM, MyMedicare and Best Practice resources
- Suggested workflows and processes
- Team roles and responsibilities.
