By January 23, 2024Acupuncture

chronic disease management (CDM) plans

Regulatory requirements

Items 721 provide rebates for medical practitioners to manage chronic or terminal medical conditions by preparing, coordinating, reviewing or contributing to chronic disease management (CDM) plans. They apply for a patient who suffers from at least one medical condition that has been present (or is likely to be present) for at least six months or is terminal.

Chronic Disease Management Plan Requirements:

A comprehensive written plan must be prepared by the usual treating practitioner describing:

a.    the patient’s documented health issue, health problems and relevant conditions;

b.    management goals with which the patient agrees;

c.     actions to be taken by the patient;

d.    treatment and services the patient is likely to need;

e.     arrangements for providing this treatment and these services; and

f.     arrangements to review the plan by a date specified in the plan.

In preparing the plan, the medical practitioner must:

a.     explain to the patient and the patient’s carer (if any, and if the medical practitioner considers it appropriate and the patient agrees) the steps involved in preparing the plan; and

b.    record the plan; and

c.     record the patient’s agreement to the preparation of the plan; and

d.    offer a copy of the plan to the patient and the patient’s carer (if any, and if the medical practitioner considers it appropriate and the patient agrees); and

e.     add a copy of the plan to the patient’s medical records.

OUR CLINIC POLICY FOR Mental Health Care Plans

1 No MHCP for new patients, and

2 MHCP only for our regular patients.

MHCP should be done by the regular treating doctor, it takes time, and requires special skills and training. Not all Gps are qualified to do MHCP.

Training Requirements

GPs providing Mental Health Treatment Plans, and who have undertaken mental health skills training recognised through the General Practice Mental Health Standards Collaboration, have access to items 2715, 2717, 92116 and 92117. It is strongly recommended that GPs providing mental health treatment have appropriate mental health training.



The assessment should be undertaken by the regular treating practitioner.

An assessment of a patient must include:

  • recording the patient’s agreement for the GP Mental Health Treatment Plan service;

  • taking relevant history (biological, psychological, social) including the presenting complaint;

  • conducting a mental state examination;

  • assessing associated risk and any co-morbidity;

  • making a diagnosis and/or formulation; and

  • administering an outcome measurement tool, except where it is considered clinically inappropriate.

In order to facilitate ongoing patient focussed management, an outcome measurement tool should be utilised during the assessment and the review of the GP Mental Health Treatment Plan, except where it is considered clinically inappropriate. The choice of outcome measurement tools to be used is at the clinical discretion of the practitioner. GPs using such tools should be familiar with their appropriate clinical use, and if not, should seek appropriate education and training.

Preparation of a GP Mental Health Treatment Plan

In addition to assessment of the patient, preparation of a GP Mental Health Treatment Plan must include:

  • discussing the assessment with the patient, including the mental health formulation and diagnosis or provisional diagnosis;

  • identifying and discussing referral and treatment options with the patient, including appropriate support services;

  • agreeing goals with the patient – what should be achieved by the treatment – and any actions the patient will take;

  • provision of psycho-education;

  • a plan for crisis intervention and/or for relapse prevention, if appropriate at this stage;

  • making arrangements for required referrals, treatment, appropriate support services, review and follow-up; and

  • documenting this (results of assessment, patient needs, goals and actions, referrals and required treatment/services, and review date) in the patient’s GP Mental Health Treatment Plan.