New GP Chronic Condition Management Plan (GPCCMP): Key updates for health professionals

From 1 July 2025, the GP Management Plan (GPMP) and Team Care Arrangement (TCA) were consolidated into a single, streamlined framework: the GP Chronic Condition Management Plan (GPCCMP). This reform is designed to simplify chronic condition management, reduce administrative burden for health professionals, and enhance patient-centred care.

Summary of key changes

Previous model:

• GPMP: A structured plan for managing chronic conditions.
• TCA: Supplemented the GPMP when multidisciplinary care was required.

Current model:

• GPCCMP: A unified plan that replaces both GPMP and TCA, allowing for more flexible and efficient care coordination.

Clinical rationale for the change

The GPCCMP aims to:

• Reduce duplication and paperwork.
• Improve patient autonomy in selecting allied health providers.
• Enable more frequent reviews (every 3 months).
• Support continuity of care, particularly for MyMedicare-registered patients.

Transition period

Patients with existing GPMPs or TCAs may continue using them until 30 June 2027. During routine reviews, clinicians should transition eligible patients to the GPCCMP.

Eligibility and scope

Patients with chronic conditions such as type 1 or type 2 diabetes, cardiovascular disease, or arthritis may be eligible. The GPCCMP must be developed by a GP or a Prescribed Medical Practitioner (PMP) within a general practice setting.

The plan includes:

• Individualised health goals.
• Required treatments and interventions.
• Referrals to allied health professionals (e.g. dietitians, credentialled diabetes educators, podiatrists).

Referral and access enhancements

• No longer requires collaboration with three health professionals to initiate.
• Referrals are valid for 18 months from the first allied health session.
• Patients may choose their preferred provider.
• Medicare-subsidised services remain available:
  • Up to five individual allied health sessions annually (10 for Aboriginal and Torres Strait Islander patients).
  • Up to five services delivered by practice nurses or Aboriginal and Torres Strait Islander Health Practitioners.
  • Up to eight group sessions for patients with type 2 diabetes.

Integration with MyMedicare

• Patients registered with MyMedicare must receive their GPCCMP and reviews from their registered practice location.
• Non-registered patients retain access to care plans but without enhanced benefits (e.g., extended telehealth consults).

Clinical considerations

Encourage patients to discuss care planning proactively, especially if:

• They are newly diagnosed or have never had a care plan.
• They require support accessing allied health services.
• They would benefit from structured goal-setting and monitoring.

Conversely, a GPCCMP may not be necessary if:

• The patient’s condition is well-managed.
• They already access required services independently.
• A structured plan would not enhance clinical outcomes.

Action for health professionals

• Review existing care plans and initiate transition where appropriate.
• Ensure MyMedicare patients are registered at the correct practice location.
• Continue regular reviews and encourage patient engagement in care planning.