Patients who have had, or are likely to have, a chronic condition for at least six months are eligible for a GP Management Plan (GPMP). Patients who also have complex care needs are also eligible for a Team Care Arrangement (TCA). The GP may be assisted by a practice nurse or other health professional in the preparation of these item numbers.

The GPMP/TCA Involves:

  • An assessment of the patient
  • Identification of management goals
  • Identification of actions to be taken by the patient
  • Identification of treatments and on-going services
  • Documentation of all of the above

To develop a TCA there must be at least 2 other health or care providers who will provide different ongoing treatments or services.

One of the other team members may be a medical specialist, as long as the specialist is involved in ongoing care.

The Practice Nurse may only be one of the team members if providing a different set of services to those provided by the GP.  The nurse must have undertaken additional education and gained expertise in the services being provided.

Team Care Arrangements require collaboration with the participating providers on required services/treatments and documentation of this in the TCA.  Communication between team members must be two way.  A blanket agreement for all patients on TCA's with an allied health professional does not meet the requirements.

cdmNet is a web based program that can manage not only the creation of General Practice Management Plans and Team Care Arrangements, but also the whole lifecycle of chronic disease care.  It allows for systematic collaborative care management of chronic disease.


MBS Search online
Aged Care
Case Conferencing
Diabetes and Asthma Cycle of Care
Health Assessments
Mental Health

Resources for providers

Health Assessment and Chronic Disease Management Flowchart

Medicare Australia Education guide - Chronic disease GP Management Plans and Team Care Arrangements

Department of Health - Questions and Answers on the CDM items
Department of Health - Chronic Disease Management Provider Fact Sheet

Online Learning available through APNA:

  • An Orientation for Nurses New to General Practice
  • Nurse Clinics in Australian General Practice - Planning, Implementation and Evaluation
  • Chronic Disease modules

Resources for allied health

Chronic Disease Management Individual Allied Health Services under Medicare - Provider Information
Medicare Australia Quick Reference Guide for allied health professionals
Chronic Disease Management Individual Allied Health Services under Medicare - Residential Aged Care Facilities

Resources for patients

Chronic Disease Management Patient Information
Chronic Disease Management Individual Allied Health Services under Medicare - Patient Information


cdmNet - Precedence Health Care

Program officer

Please contact our office to speak to the appropriate Program Officer
P: 5222 0800