Chronic Disease Management Overview


The Chronic Disease Management (CDM) program works to engage with GPs, AHPs, practice nurses and practice staff to enhance chronic disease management and optimise preventative health strategies.

The program offers support, training and assistance with:

  • MBS Primary Care items e.g. health assessments, care plans, asthma and diabetes service incentive payments
  • Best practice guidelines and clinical support systems
  • The use of screening tools e.g. diabetes risk assessment tool (AUSDRISK), cardiovascular risk calculator
  • Coordinating patient care e.g. referral pathways
  • Quality Improvement activities that utilise the Pen CAT data extraction tool e.g. Putting Data into Practice initiative 

Project officers are available to provide information, support and resources via practice visits, telephone/email and workshops.

external link Click here to read more about Care Plans

external link Click here to read more about Allied Health Professional Resources

external link Access to TIS National interpreting service for AHPs

external link Free Access to TIS National interpreting service for GPs and NGOs