Chronic Disease Management

Brisbane North PHN works with primary healthcare providers to support patients who are living with chronic disease. 

A patient with a chronic medical condition that has been (or is likely to be) present for six months or longer is eligible for Chronic Disease Management (CDM) services on the Medicare Benefits Schedule. CDM Medicare items enable GPs to plan and coordinate the care of patients with complex conditions requiring ongoing care from a multidisciplinary team.

Brisbane North HealthPathways

Brisbane North HealthPathways includes local pathways for a range of chronic conditions. For more information visit our Pathways Program page.

Resources

Below are useful links and resources about CDM for health professionals:

Chronic disease resources

Primary care (GP, nursing, allied health) – Medicare primary care items for Medicare rebates - Department of Health

RACGP Putting Prevention into Practice (Green Book) – guidelines for the implementation of prevention in the general practice setting (2nd edition)

RACGP Clinical guidelines for preventative activities in general practice (Red Book)

RACGP Clinical guidelines – national guide to a preventative health assessment for Aboriginal and Torres Strait Islander people

Chronic disease management e-Learning package – an online learning program with eight disease modules covering a range of topics - Australian College of Nursing

Chronic Conditions Manual – Sections 1 – 5 – Queensland Department of Health

Chronic Conditions Manual – Section 1: Lifestyle modifications – Queensland Department of Health

Chronic Conditions Manual – Section 2: Management of diagnosed conditions – Queensland Department of Health

Chronic Conditions Manual – Section 3: Child health checks – Queensland Department of Health

Chronic Conditions Manual – Section 4: Adult health checks – Queensland Department of Health

Chronic Conditions Manual – Section 5: Appendices – Queensland Department of Health

Chronic Conditions Manual – Section 5: Cardiovascular risk charts – Queensland Department of Health

Chronic Conditions Manual – Section 5: Type 2 diabetes risk assessment tool – Queensland Department of Health 

Chronic Conditions Manual – Section 5: Medicare items – Queensland Department of Health

Care Plans and Templates

Department of Health Chronic Disease Management – GP services – lists the CDM items, fact sheets, Q&As, resources for providers and resources for patients

MBS Online – Department of Health Medicare Benefits Schedule (MBS) and a list of Medicare services subsidised by the Australian government

Brisbane North PHN frequently used desktop guide to item numbers for general practice

Coordinated Veterans’ Care Program

Coordinated Veterans’ Care Program factsheet – Department of Veterans’ Affairs