Chronic Disease Management

Grampians Medicare Local provides resources, education, training and support to health professionals and practice staff to assist with the prevention and management of chronic diseases.

In particular we offer support around:

  • MBS Primary Care items: health assessments, care plans, asthma and diabetes service incentive payments
  • Best practice guidelines and clinical support systems
  • Coordinating patient care: referral pathways, access to Allied Health services
  • Quality Improvement activities that utilise the Pen CAT data extraction tool
  • Setting up and maintaining effective recall/reminder systems and data cleaning
Chronic Disease Management (CDM) Medicare Items

For information on Chronic Disease Management (CDM) items, including MBS item descriptors, explanatory notes, questions and answers, an overview fact sheet and example scenarios regarding the use of CDM items. Click here to link to DOHA information.

MBS support

You can now directly email Medicare Australia with any question you have relating to Medical Benefits Schedule (MBS) items at Questions will be answered by a centralised specialist team, who are trained to respond to these often complex MBS interpretation questions.

ADF Post Discharge Health Assessment Information (New - available on MBS Online from 1/7/14)

Medicare Australia

MBS online

Quick reference guide for GPs (Medicare Australia)

MBS quick reference guide for Allied Health

PIP and SIP (for accredited practices)

All Accredited General Practices are eligible for the Practice Incentive Program (PIP).

PIP guidelines

Quality Prescribing Incentives guidelines

The Coordinated Veterans’ Care (CVC) Program

The CVC Program is a new way for primary health care providers to assist Department of Veterans’ Affairs Gold Card holders who have chronic conditions and complex health needs.
Through improved community based care, the program is intended to avoid an unplanned hospital admission and improve the health of participants. Led by a GP, with a nurse coordinator, the CVC Program provides ongoing, planned and coordinated primary and community care.
For further CVC program information visit the Coordinated Veterans’ Care program.


We are able to assist with data extraction from your system to identify patients with recognised chronic diseases. We provide data cleaning including training in the use of the PENCAT audit tool. We can install the PENCAT software which allows general practices to easily view and analyse their clinical data and highlight areas where improvements can be made. PENCAT

Cat recipes provide instructions on how to use CAT to extract and analyse data. CAT Recipes


Chronic disease is one of the greatest challenges to health care as we know it. To address this challenge, precedence health care has created cdmNet, a web based service that assists general practice, health care providers and patients better manage chronic conditions and other illnesses. Using cdmNet, any member of a patients care team can access the patients health record and care plan, including the GP, practice nurse, specialist, allied health, pharmacist, and patient themselves. We are able to assist with the setup and training around the use of cdmNet. Find out more: cdmNet

Allied Health Resources

Allied Health Professions Australia (AHPA) provides information on Allied Health skills and discipline-specific competencies, a guide to Medicare’s chronic disease management items and working with general practice staff

Sharing the care and understanding between General Practices and Allied Health Professionals

Steps to be completed to claim Allied Health services

Chronic Disease Management - Resources >>>



Cardiovascular Disease

Care Plans



Health Assessments


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