A care plan works best when it changes with you
A GP Chronic Condition Management Plan is not meant to be written once and forgotten.
The first plan sets out where things stand, what you want to improve and who may help. The review is where you check whether any of that is actually working.
That may mean continuing the same approach. It may mean changing a goal, adjusting monitoring, reconsidering a referral or simply acknowledging that progress has been slower than expected.
A good review is not about ticking another Medicare box. It is about asking: What has changed, what is helping, and what should we do next?
What is a care plan review?
A review is a structured follow-up of your existing GP Chronic Condition Management Plan, or GPCCMP.
Current Medicare arrangements allow GPCCMP reviews for eligible patients with chronic or terminal medical conditions.
- how your condition has changed
- whether your treatment is working
- progress towards your goals
- blood tests or other monitoring
- medicines
- allied health treatment
- specialist recommendations
- new symptoms or diagnoses
- preventive healthcare that may be due
- what is getting in the way of progress
- whether the original plan still makes sense
The aim is not necessarily to change something. Sometimes the right decision is to continue what you are already doing.
Why review a plan if nothing has gone wrong?
Because chronic conditions change gradually.
Blood pressure may improve. Diabetes control may drift. Pain may settle enough to increase activity. A medication may work but cause unwanted effects. A physiotherapist may identify a different problem from the one originally suspected.
Your priorities can change as well.
A goal that seemed important six months ago may no longer matter. Another issue may now be affecting your daily life more.
Without review, a care plan can become a snapshot of how things used to be rather than a useful guide to your current care.
When can a care plan be reviewed?
Under the current Medicare framework, Medicare benefits for a routine GPCCMP review are generally available no more often than once every three months, unless exceptional circumstances apply.
That does not mean every patient needs a Medicare care plan review exactly every three months. The timing should make clinical sense.
- a new treatment has started
- you are actively working towards several goals
- allied health professionals are involved
- important blood tests need repeating
- symptoms or function are changing
- several chronic conditions need coordination
Someone whose health is stable may need less frequent structured review.
The purpose should drive the appointment, not the calendar.
Why does review matter for allied health access?
A current GPCCMP can also support Medicare-subsidised allied health services.
For these services, current Medicare rules generally require the GPCCMP to have been prepared or reviewed within the previous 18 months.
This is another reason an old plan should not simply sit in the medical record indefinitely.
But keeping Medicare eligibility active should not be the only reason for reviewing it. The bigger question is whether the allied health care is helping.
What should happen with allied health reports?
If you have seen a physiotherapist, podiatrist, dietitian, exercise physiologist or another allied health clinician, their feedback can be useful at your review.
- Is your strength improving?
- Is your walking becoming easier?
- Has your diet changed in a sustainable way?
- Is your foot risk improving?
- Are you actually able to follow the exercise programme?
- Does the allied health clinician recommend continued care or a different approach?
The point of coordinated care is that these appointments should not exist as completely separate pieces of healthcare.
Your GP can help bring the information together.
A review is not just about whether you “completed” your goals
Health goals are not school assignments.
If you planned to exercise four times each week and managed once or twice, the review should not simply record that you failed.
A more useful conversation is: What made it difficult?
Perhaps pain stopped you. Perhaps the exercise plan was unrealistic. Perhaps work or caring responsibilities made it impossible. Perhaps you simply chose a goal that did not matter enough to you.
The answer may be to make the goal smaller, find another approach or concentrate on something else.
A good plan should adapt to your life rather than repeatedly asking you to fit your life around the plan.
What might your GP check at a review?
This depends on your conditions and goals.
For someone with diabetes, the review might include:
- HbA1c
- blood pressure
- kidney monitoring
- cholesterol
- medicines
- weight
- physical activity
- foot care
- eye screening
- nutrition
For someone with arthritis or persistent pain, it may focus more on:
- pain and function
- mobility
- exercise
- strength
- sleep
- medicines
- work or daily activities
- physiotherapy or exercise physiology
For someone with several conditions, the review may be less about one particular number and more about making sure the treatments fit together.
Medicines deserve another look
A chronic condition review is a useful opportunity to revisit medicines.
- Are you actually taking them?
- Are they helping?
- Have you developed side effects?
- Has the dose changed elsewhere?
- Are several doctors prescribing medicines?
- Are any medicines no longer necessary?
- Is monitoring due?
Do not stop prescribed medicines because of something you read in a health guide.
But if you are not taking a medicine, are worried about it or believe it is causing problems, tell your GP.
An accurate medication list is much more useful than a perfect-looking list that does not reflect what you actually take.
What if my results have not improved?
That does not automatically mean the plan has failed.
Sometimes change takes longer than expected. Sometimes the original goal was too ambitious. Sometimes the treatment has not worked. And sometimes the measurement we chose was not the most useful one.
For example, a person’s weight may change very little while their fitness, strength, blood pressure or diabetes control improves.
The purpose of review is to interpret what has happened rather than simply judge whether a target was reached.
What if everything is going well?
That is useful information too.
- keep the same treatment
- continue an exercise programme
- maintain the same medicines
- reduce the frequency of follow-up
- set a new goal
- move the focus towards prevention
Good chronic disease care is not about constantly finding something else to treat.
Sometimes the best outcome is that a sensible plan is working and does not need much change.
A common misconception
MYTH: A care plan review is just a repeat of the original appointment.
REALITY: The first plan establishes the problem, goals and care arrangements. A review should ask what has happened since then and whether the plan still fits your health and priorities.
If nothing has changed, the review can confirm that. If something has changed, the plan should change with it.
Questions patients commonly ask
Do I need another new care plan every year?
Not necessarily.
Under the current Medicare framework, preparation of a new GPCCMP and review of an existing plan are different services. A new plan can generally be prepared once every 12 months, while Medicare benefits for routine reviews are generally available no more often than every three months when clinically appropriate.
Often it makes more sense to update a useful existing plan than repeatedly start again.
Does a review give me another five allied health visits?
No.
For most eligible patients, the limit is up to five individual allied health services per calendar year, regardless of how many times the plan is reviewed. Eligible Aboriginal and Torres Strait Islander patients can access up to 10 individual services under the current chronic-condition allied-health rules.
A review does not reset the annual allocation.
What if I have used all my allied health visits?
You can still review your chronic condition management.
The GPCCMP is about your overall care, not simply allied health rebates.
Your GP can discuss what should continue, what you can do independently and whether other treatment options are appropriate.
Do I have to wait three months if my health suddenly changes?
No.
The three-month interval is the usual Medicare claiming rule for routine reviews. Exceptional circumstances can allow earlier review when there has been a significant change in your condition or care needs.
A new or worsening medical problem should also be assessed when clinically necessary rather than waiting for a scheduled care plan review.
How to prepare for your review
You do not need to arrive with a folder full of paperwork.
Before the appointment, consider:
- What has improved since the plan started?
- What is still causing trouble?
- Which treatments or appointments have actually helped?
- What have I found difficult to do?
- What matters most to me over the next few months?
Bring useful information if you have it, such as:
- home blood pressure readings
- blood glucose readings
- an updated medication list
- letters or reports from clinicians outside your usual practice
- information about significant new diagnoses or hospital visits
Your GP may already have much of this information.
Start with one question
At your next review, ask: “Is this plan still focused on the things that matter most for my health?”
That question can be more useful than simply asking when your next referral is due.
The bottom line
A GP Chronic Condition Management Plan is most useful when it remains current.
The review is where you look at what has happened since the plan was created, decide whether the goals and treatments are helping and make adjustments when they are not.
For some people that means changing several things. For others it means confirming that the current approach is working.
Either way, the review should leave you with a clearer understanding of:
- What is improving?
- What still needs attention?
- What are we doing next?
Related Q Guides
Important information
This guide provides general health information and does not replace personalised medical advice. Speak with your GP or healthcare professional about recommendations appropriate to your medical history and circumstances.
Evidence and further reading
- Services Australia — Requirements for a chronic condition management plan
- Services Australia — MBS billing rules for GP chronic condition management plans
- Services Australia — MBS billing rules for chronic condition allied health and other primary health care items
- Services Australia — Services available under a GP chronic condition management plan