How to Build a Highly Effective Chronic Disease Strategy for Your Practice

Chronic disease management has become an increasingly large component of general practice. Caring for people with chronic diseases is a major requirement of the health system with an estimated $60 billion being spent annually on such support. This adds a lot of strain on general practices, which are usually the patient’s first point of contact with the medical profession. Such practices play a key role in the early diagnosis and care of people from our community who suffer from chronic disease.

But, how does a general practice stand up against the increasing pressure to manage more and more complex patients, with such limited time and resources? This article explores the building blocks necessary to help practices better improve chronic disease management.

1. Know What Affects Your Patient Population

The first building block to improving chronic disease management is understanding what is affecting your practice’s patient population. While many GPs, practice managers and practice nurses know how many patients are diagnosed with diabetes, they are often less aware of the number of patients who are diagnosed with asthma, COPD, osteoporosis, coronary heart disease or arthritis.

This is where clinical software programs, or data extraction tools, can help by easily breaking down an entire patient population into disease cohorts. The fact is, we often focus a big chunk of our time and resources on one disease cohort, believing this is a high priority area, when data extraction more often than not shows us that a large patient cohort has been completely overlooked.

Start by looking at the data and finding out exactly what is affecting your patient population. From here you can then direct your scarce resources to where they are needed most.

2. Take Control – Reactionary vs Intentional Patient Management

The second building block for improved chronic disease management is shifting from reactionary care to intentional care. How often are your patients being seen for chronic disease management appointments because they have run out of referrals? How often are your patients being seen for chronic disease management appointments because they have urgent care needs? What if you could intentionally target patient cohorts for chronic disease management before there was a crisis?

Again, this is where data extraction tools come into play. Such tools allow a practice to identify patient populations who are at a higher risk of a poorer outcome. For instance, which of your diabetic patients are uncontrolled? Which heart disease patients are at an increased risk of a medication mishap? Intentional patient care means being active in seeking out those patients who need your help the most, and focusing your scarce resources on helping them. As opposed to reactionary support where we wait for the patient themselves to ask for help.

3. The Nurse’s Role in Chronic Disease Management

The third building block for improved chronic disease management is better utilising the role of the practice nurse. In an article titled, A Nurse-Led Model of Chronic Disease Management in General Practice: Patients’ Perspectives, published in The Australian Family Physician, the argument is put forward that the practice nurse could play a lead role in the coordination of chronic disease management by using practice data to target those population groups in need of the most help.

It’s no surprise that practice nurses are becoming increasingly involved in the care of people with chronic diseases in their day-to-day work. Most successful interventions in chronic disease management require a team effort. If the primary care doctor couldn’t delegate many of the responsibilities to team members, including practice nurses, there is simply no way the patient would receive the best available clinical and self-management support services. This shift requires nurses to take ownership over these tasks. They, after all, are the key drivers in keeping chronic disease management plans on track.

4. Building a Business Model for Chronic Disease Management

The fourth building block in improving chronic disease management is a sound understanding of the financial implications. Limited resources, the Medicare freeze, and changes to funding models make it imperative that general practices stay on top of what funding is available for what services.

The Medicare Australia’s Provider Percentile Chart (Apr ‘13 – Mar ‘14) reports that only 5% of registered GPs claimed more than 236 services relating to GP Management Plans, translating to only 4.5 GP Management Plans provided during the average working week. This is despite the fact that, conservatively, the average patient attending a practice for chronic disease management over 2 years equates to approx. $1,152 in MBS billings.

There are multiple reasons for this, but the main contributor is uncertainty around MBS claiming rules. The key step here is to become familiar with the chronic disease management MBS items involved in improved billing practices. That way your practice can take full advantage of the funding on offer.


Chronic disease is not going away anytime soon. And with practices taking on the brunt of setting up and supporting patients with chronic disease management plans, it is imperative that your practice assembles a well thought out plan of attack so you can provide the highest quality support to your patients. This means adopting a collaborative approach based on the four key building blocks – understanding who your patient population is, intentionally targeting those at higher risk, developing a chronic disease management team, and keeping on top of Medicare funding.

If your practice can focus on these four key areas alone you will inevitably improve the level of support you can provide in chronic disease management. Maybe not overnight, but certainly over time.

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