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The implementation of Chronic Disease Management (CDM) programs within General Practice settings are crucial, largely thanks to their potential to significantly enhance the quality of life of patients suffering from chronic health conditions.

With approximately 47% of Australians have one or more chronic conditions in 2020-2021, and the steady rise in diagnoses of chronic conditions, CDM is becoming one of the greatest challenges faced in general practice.

Planning, delivering and improving on a great CDM program is always a challenge. This article is a guide to help kickstart your CDM program in 2023.

Identifying patients potentially eligible for CDM

The first step in growing a successful CDM program is to identify patients who have one or more chronic conditions. Chronic conditions are those that have been or are likely to be present for at least 6 months. This includes conditions such as asthma, cancers, cardiovascular disease, diabetes, kidney disease, musculoskeletal conditions and stroke to name a few.

General Practices have access to a range of tools and resources that can assist to identify and create records of patients with chronic conditions. These tools and resources include PenCS, Cubiko and Practice Management Systems with access to limited reporting. Patients that have been identified as having a chronic condition may be eligible for subsidised health services provided under a General Practice Management Plan (GPMP) or a Team Care Arrangement (TCA). We recommend that you always consult the MBS and your practitioner on when you may be eligible to claim on a patient’s behalf, and what the minimum claiming periods are for each of these items.

From there, you can identify which of your patients historically meet the criteria of having a chronic disease, but do not have a current GPMP or TCA in place. Download these lists for your reception and nursing team to reach out to and book them in for an appointment with your CDM team.

Using data to engage your patients

Patient engagement is key to the continued care of patients with chronic conditions.

Utilising your practice data and having access to the right technologies can help make it easier to find those patients who may be eligible or overdue for a CDM service. Without these tools and technologies, extracting this data can be complex and time-consuming, requiring you to run custom scripts in your practice management system to pull the data.

Our friends at leading Practice Intelligence Platform provider Cubiko have been helping practices across Australia.

“Over the last 3 months we’ve seen a significant increase in the number of care plans performed… just looking at the numbers we’ve completed 4 times as many care plans than we did this time last year thanks to Cubiko” – Amber Meaclem, One Care Family Doctors. Learn more.

Cubiko’s Item Optimisation feature provides you with the metrics and data to help you gain insights into the patients who may be eligible or overdue for these services. Provide these lists to your nursing team so that they can work with doctors to prioritise the patients who may be high risk or need care soonest. Your nursing team can then work through the list to engage with these patients and get them to book an appointment.

Another avenue you can take is involving your practitioners in patient engagement for proactive patient care with Cubiko’s Doctor Direction Sheet, which you can download here. Have your practitioners fill out the direction sheet before the patient leaves the consulting room to indicate which services they want the patient to book in for next.

Empower your CDM team

Running a thriving and successful CDM program is challenging. To help ensure the success of your CDM program, it’s important that you have a dedicated team of practitioners, nurses and support staff who are passionate about providing proactive care to patients with chronic conditions.

Setting goals

Set goals on what you’d like your CDM program to achieve. While many have ambitious plans for their CDM program, it’s important to set realistic goals on what you’d like your team to achieve. It could be to grow your CDM program by 1-2% each month or simply get all your patients with out-of-date Care Plans back up to date.

Managing capacity

Next, it’s important that you look at your team’s capacity and appointment availability before contacting patients and booking them in. While your team may be keen to see and treat your CDM patients, they may not have the capacity to do so. The last thing you want is to ask a patient to book an appointment, but not have availability. This data can also come in handy to help you find seasonally slower periods in your practice where reaching out to eligible CDM patients can become a priority.

Growing your team

Many practices are looking to grow their CDM program by growing their CDM team. While this is fantastic for your practice and your patients who are chronically ill, it’s important to take a step back and examine the financial viability of expanding your team to grow your program. Working with a trusted accountant or advisor can help you make the right financial decision for your practice.

Bringing your team on the journey

Lastly, and arguably one of the most important things is to ensure that you bring your team along on the journey. The success of your CDM program is reliant on your team’s participation from your admin team, to your nurses, to your practitioners. It’s important that you’re encouraging your team and provide them with the training, support, and tools to help them succeed at their job. In turn, your patients and CDM program will reap the rewards.

If you’re interested in learning more about how Cubiko can help you optimise your CDM program book in for a demo today. For more information telephone 1300 CUBIKO (1300 282 456) or email

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