Chronic Diseases are the leading cause of death and disability in Australia.

Chronic diseases include cancer, cardiovascular disease, chronic kidney disease, diabetes, respiratory conditions (including Asthma), and musculoskeletal conditions (Arthritis and Osteoporosis).

Northern Queensland Primary Health Network (NQPHN) supports better management of chronic and complex conditions in the following ways:

  • Encouraging GPs to provide Chronic Disease Care Plans
  • Supporting practices to manage their data and identify patients with chronic disease or associated risk factors early
  • Providing training and education around chronic disease
  • Running Quality Improvement Collaboratives

National chronic disease strategy
The national chronic disease strategy provides an overarching framework of national direction for improving chronic disease prevention and care across Australia.

Insulin Medications

Northern Queensland Primary Health Network (NQPHN) supports Chronic Disease Management that is:

  • patient centred
  • continuous and provides consistent care
  • intended to keep people as well as possible
  • delivered as close to peoples home as possible
  • coordinated using integrated team based approaches
  • evidence based
  • enables self-management.

Increasing access to allied health care is an important component of improving regional, rural, and remote health outcomes. NQPHN currently funds the below organisations to deliver allied health services for people in rural and remote areas:

In December 2017, KP Health completed a review of Chronic Care Services in northern Queensland. Download the review here.

Chronic Disease Management and MBS

The Chronic Disease Management (CDM) – formerly Enhanced Primary Care or EPC – Medicare items are for General Practitioners (GPs) to manage the health care of people with chronic or terminal medical conditions, including those requiring multidisciplinary, team-based care from a GP, and at least two other health or care providers.


A person who has a chronic or terminal medical condition (with or without multidisciplinary care needs) can have a GP Management Plan (GPMP) service.

A person with a chronic or terminal medical condition and complex care needs, requiring care from a multidisciplinary team, can have a GPMP and Team Care Arrangements (TCAs).

A chronic medical condition is one that has been (or is likely to be) present for six months or longer, for example, asthma, cancer, cardiovascular disease, diabetes, musculoskeletal conditions and stroke. There is no list of eligible conditions. However, these items are designed for patients who require a structured approach to their care and to enable GPs to plan and coordinate the care of patients with complex conditions requiring ongoing care from a multidisciplinary team.


GPMPs and TCAs can be reviewed by a GP from the same practice or, if the patient changes practices, by a new GP. Using the CDM items, GPs can contribute to other provider’s multidisciplinary care plans and to a review of these plans. GPs can be assisted by practice nurses, Aboriginal and Torres Strait Islander health practitioners, Aboriginal and Torres Strait Islander health workers and other health providers, in preparing and reviewing the CDM items, but the GP must meet all the Medicare requirements of the items.

For more information, visit:

  • Preparation of a GPMP – Item 721

    For patients who are having a multidisciplinary care plan prepared or reviewed by another health or care provider (other than their usual GP).

    The minimum claiming period is once every three months however, this can be earlier if clinically required.
    It involves the GP (who may be assisted by their practice nurse or other) collaborating with the providers preparing or reviewing the plan, and including their contribution in the patient’s records.

  • Review of a GPMP – Item 732

    This is for patients in residential aged care facilities and is otherwise identical to Item 729.

  • Coordination of a Review of TCAs – Item 732

    For patients requiring a review of their current TCAs.

    The minimum claiming period is once every three months however, this can be earlier if clinically required.

    It involves the GP (who may be assisted by their practice nurse or other) collaborating with the participating providers on progress against treatment/services and documenting any changes to the patient’s TCAs.

  • Coordination of TCAs – Item 723

  • Contribution to a Multidisciplinary Care Plan being prepared by another Health or Care Provider – Item 729

    Provides a rebate for a GP to prepare a management plan for a patient who has a chronic or terminal medical condition with or without multidisciplinary care needs.

    The minimum claiming period is once every 12 months, supported by regular review services.

    It involves the GP assessing the patient, agreeing management goals with the patient, identifying actions to be taken by the patient, identifying treatment and ongoing services to be provided, documenting these, and including a review date in the GPMP.

  • Contribution to a Multidisciplinary Care Plan being prepared for a Resident of a Residential Aged Care Facility – Item 731

    Provides a rebate for a GP to review a GPMP (see above).

    The minimum claiming period is once every three months; can be earlier if clinically required.

    It involves reviewing the patient’s GP Management Plan, documenting any changes, and setting the next review date.

  • Access to Allied Health Items

    Patients who have both a GPMP (item 721) and TCAs (item 723) may be eligible for the individual allied health services on the Medicare Benefits Schedule. Similarly, residents of residential aged care facilities whose GP has contributed to a care plan prepared by the residential aged care facility (item 731) may also be eligible for these allied health items.

    Eligible patients can claim a maximum of five allied health services per calendar year (MBS items 10950-10970).

    Patients with a GPMP (item 721) and type 2 diabetes can also access Medicare rebates for allied health group services (MBS items 81100 to 81125). Patients need to be referred by their GP for services recommended in their care plan, using the referral form issued by the Department or a form that contains all the components of the Department’s form.

  • Practice Nurse Monitoring and Support

    Patients with either a GPMP or TCAs can also receive monitoring and support services from a practice nurse or Aboriginal and Torres Strait Islander health practitioner on behalf of the GP (MBS item 10997).

Chronic and complex conditions self-management

What is meant by self-management? We often hear of people with complex conditions as being non-compliant, not carrying out tasks associated with care, or simply not filling out scripts. Why does the health focus need to change to one of self-management?

  • 21% of people never fill prescriptions
  • 55% don’t take medications as recommended
  • 30% of gym memberships are not active.

Self-management refers to our individual understanding and how we manage everyday situations regarding our health with support from the doctor, nurse and allied health workers. It becomes a complex array of people, instructions and outcomes.

The definition of self-management as developed by the Centre of Advanced Health SA 1996 is: ‘Self-management involves (the person with the chronic disease) engaging in activities that protect and promote health, monitoring and managing the symptoms and signs of illness, managing the impact of illness on functioning, emotions and interpersonal relationships, and adhering to treatment regimes.”


Health Professionals are asked to increase their core skills to include a review of the way we collect information. Core skills include: motivational interviewing; reflective listening and open ended questions; problem solving; goal setting; planning; identifying follow up needs including a person’s readiness to change; assertive skills; assessing suicide risk; and depression screening.

Chronic and complex conditions resources