Chronic Condition Management Plans (Care Plans)

#Chronic Condition Management Plan (Care Plan)

Plan date:
Review date:
 
SIGNIFICANT CHRONIC CONDITIONS
1.
2.
 
SIGNIFICANT HEALTH RISKS
General:
(-) Nutrition
(-) Overweight/obesity
(-) Underweight
(-) Chronic pain
(-) Planned/recent surgery
 
ADL / Functional:
(-) Self-care
(-) Communication
(-) Physical activity
(-) Sensory function
(-) Hand function
(-) Travel and mobility
(-) Meal preparation
(-) Shopping
(-) Home maintenance/cleaning
(-) Managing finances
 
Cardiovascular:
(-) ASCVD
(-) HF
(-) Other ->
Respiratory:
(-) Limited exercise tolerance
(-) Sputum production
 
Musculoskeletal:
(-) Osteopenia/osteoporosis
(-) Sarcopenia
(-) Falls
(-) Mobility
(-) Physical independence
 
Neurological:
(-) Vision
(-) Hearing
 
Mental health:
(-) Isolation/loneliness
(-) Cognition
(-) Anxiety/depression
 
Medication-related:
(-) Complex pharmaceutical regimen – potential for errors
(-) Adverse reactions
 
GP MONITORING (what; when)
Medication review; every 12 months
 
ALLIED HEALTH REFERRALS (services; why; how many sessions)
(-) Audiologist
(-) Chiropractor
(-) Diabetes educator
(-) Dietitian
(-) Exercise physiologist
(-) Mental health worker
(-) Occupational therapist
(-) Osteopath
(-) Physiotherapist
(-) Podiatrist
(-) Psychologist
(-) Speech pathologist
(-) Other ->
 
MEDICAL SPECIALIST REFERRALS
 
OTHER REFERRALS
(-) My Aged Care
(-) NDIS
 
REGULAR INVESTIGATIONS (what; when)

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Chronic condition management plans (CCMP)

NOTE: From 1 July 2025, Medicare Benefits Schedule (MBS) items will be changing to replace the current GP Management Plan and Team Care Arrangements with a single GP Chronic Condition Management Plan.

Referrals to allied health providers can be done using standard referral letters or forms.

MBS (Australia) item numbers

Chronic Condition Management Plans (CCMP)
- Plan preparation - face to face: 965
- Plan prepatation - video: 92029
- Plan review - face to face: 967
- Plan review - video: 92030
45-49 Year Old Preventive Health Assessment: 701-707
75+ Year Old Preventive Health Assessment: 701-707

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