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Chronic Conditions Management – change activities for general practice

It’s time to prepare your general practice for changes to Chronic Conditions Management (CCM) MBS items. Chronic Conditions Management (CCM) MBS item changes recommended by the MBS Review Taskforce are ‘the first major change to chronic disease management in 20 years’, and are scheduled to come into effect 1 July 2025.

To help your practice prepare to transition to CCM with small, manageable changes, Northen Territory PHN invites your practice to participate in our CCM activation series of high impact change activities with your practice team and patients to implement new chronic conditions management items, strengthening the connections that patients have with your practice through MyMedicare.

We look forward to supporting you through this CCM activation series!

Activity 1 will focus on practice preparation:

  • Registering your practice for MyMedicare
  • Call to Action: Communicate with practice team
  • Data Cleansing
  • Patient awareness

There are a range of ideas outlined in activity one for you to use to tailor and modify to assist you develop your plan for change at your practice. We suggest you document your plan for Activity 1 below using a Plan-Do-Study-Act template. Ensure responsibility for each activity is allocated to a member of your practice team with a timeline for completion.

The following Activity 2 focuses firstly on strengthening patient-practice relationships by registering Chronic Disease Management Patients for MyMedicare, and routine scheduling of patients for Chronic Disease Management Reviews.

As the new year rolls around, many of your existing patients with chronic disease management plans will be due for a new chronic disease management plan and team care arrangements. Patients and practices often time chronic disease management plans with the start of the calendar year, when allied health items available through team care renew (items 10950 to 10970 and 81100 to 81125).

Activity 3 aims to raise awareness among your practice team of MyMedicare, Chronic Conditions Management changes and support your team to explore their roles in both MyMedicare and Chronic Conditions Management. By exploring and defining these roles, your practice team can work collaboratively to prepare for change and develop processes, systems and skills needed to succeed. This process will help ease your team through change and provide a shared document that can help your team to identify and discuss anything that isn’t quite working as planned, explore changes and update the document to keep everyone on the same page. This approach will allow your team to adapt and improve and empower each team member in their own role.

Don’t forget to record your plan in the Plan-Do-Study-Act template.

Activity outcomes:

  1. Your practice team has a better understanding of MyMedicare(Voluntary Patient Registration)
  2. Your practice team has a better understanding of the proposed Chronic Conditions Management changes
  3. Your practice team roles in MyMedicare and Chronic Conditions Management are well defined, and each team member has a clear role and responsibilities

Activity 4 takes a focus on enhancing MyMedicare patient engagement and registration communications. Outcomes of Activity 4 for your practice include:

  1. Understand how MyMedicare is evolving, and the current and future benefits.
  2. Develop a shared practice team perspective of how MyMedicare aligns with your practice’s approach to patient care.
  3. Develop key messages, benefits and talking points that your practice team can use to consistently communicate to patients about Chronic Conditions Management and MyMedicare.
  4. Develop a plan for targeting patient populations using different communication mediums and channels to increase MyMedicare registration for regular patients of your practice.

We suggest you document your undertakings for this activity using the Activity 4 Plan-Do-Study-Act template, ensure responsibility for each action and allocated to a member.

Activity 4 resources:

These tools are designed to streamline communication and boost patient engagement in MyMedicare, ultimately strengthening continuity of care and enabling better chronic condition management.

Need assistance?

Please contact our practice support team to request assistance and support with the upcoming CCM changes by emailing: practicesupport@ntphn.org.au.