From 1 July 2025, Australia’s revised Chronic Disease Management (CDM) program will come into effect—bringing important changes to how general practices deliver care plans and structure long-term patient support.

While any national update brings questions, this one offers a meaningful opportunity: to make chronic care more consistent, more accessible, and more sustainable—for both patients and clinicians.

Here are five ways these changes may affect your practice, and how you can prepare.

1. Core CDM Item Numbers Are Changing

The existing item numbers for GP Management Plans (GPMP) and Team Care Arrangements (TCA)—including 721, 723, and their associated review items—will be replaced with a single GP Chronic Condition Management Plan (GPCCMP) item for both preparation and review.

The new item numbers are:

• 965 – for care plan preparation
• 967 – for review
  Each carries a rebate of $156.55 and removes the need for allied health signatures or external referral documentation.

What this means for GPs:

• You’ll need to update billing templates and workflows in your clinical software (e.g., Best Practice).
• With less paperwork, care plans can be completed during a standard consult—reducing disruption to your day.
• Less admin means more time for clinical focus, not chasing signatures.

What this means for patients:

• More patients can now access structured care without needing additional appointments or external referrals.
• The simplified process may mean they receive care plans sooner.
• This change removes barriers and makes care planning part of their usual GP experience.

2. More Patients Will Now Be Eligible for CCM Support

Eligibility criteria have expanded under the new model. Previously, only a small subset of patients received care plans—often due to time constraints and system complexity. Now, it’s estimated that up to 60% of a GP’s patient base may qualify.

What this means for GPs:

• You’ll be able to offer CCM support to more patients who need it—but scaling this support sustainably will be essential.
• Efficient identification of eligible patients (e.g., through Cubiko) can help avoid overwhelm.
• It’s an opportunity to improve population health while maintaining clinical efficiency.

What this means for patients:

• Many patients with chronic conditions who didn’t previously qualify may now be included in CCM support.
• This means more people receiving ongoing, proactive care—instead of episodic attention.
• It helps bridge care gaps, particularly for under-served populations.

3. Streamlined Workflows Are No Longer Optional

The intention behind the new CCM structure is to make care planning more feasible within regular consults. But this only works if practices have systems that support documentation, tracking, and eligibility—without adding more admin burden.

What this means for GPs:

• Care planning can finally fit into standard appointments—if your tools are ready.
• You’ll need workflows that integrate eligibility checks, pre-filled documentation, and review scheduling.
• Without streamlined tools, there’s a risk of reverting to time-consuming processes.

What this means for patients:

• Patients are more likely to have their care plan completed during their consult, without being asked to come back or wait weeks.
• Their care journey becomes simpler, with fewer handoffs and fewer missed opportunities for support.
• A smoother system supports greater trust and engagement with their GP.

4. Regular Reviews Now Play a Central Role

Unlike the previous model—where initial care plans had higher rebates and reviews were undervalued—the new CCM structure places equal importance (and equal rebates) on reviews. This supports true continuity of care.

What this means for GPs:

• Your team will need to track and schedule reviews reliably—every 3 months—to maintain alignment with the new CDM model.
• Tools like Lyrebird help automate this tracking within your usual workflow.
• Reviews are no longer secondary—they’re a core part of sustainable care delivery.

What this means for patients:

• Patients will be seen more consistently and reviewed proactively, rather than falling through the cracks.
• This enables early intervention, better health planning, and clearer expectations around follow-up.
• It builds a stronger therapeutic relationship over time.

5. Practices Will Need to Adapt to Remain Sustainable

The rebate for a single CDM item is lower than the combined GPMP + TCA model, but the structure is more scalable. Practices that adopt the right tools and workflows can offer care to more patients, more consistently—without burnout.

What this means for GPs:

• Delivering care plans efficiently is now essential for both clinical and operational sustainability.
• Practices that adapt early will avoid disruption and reduce the risk of revenue decline.
• This is an opportunity to make chronic care both more equitable and more viable.

What this means for patients:

• Patients benefit when their clinic runs efficiently and consistently.
• With smoother systems, they’re more likely to receive the care they need on time.
• More eligible patients means more people feeling supported in their health journey.

🔍 Lyrebird’s CCM-Ready Workflow (Available July 1)

Lyrebird has built the capability to support practices through the CCM transition—aligned specifically with the new MBS structure and available from July 1 and out of the box for BP users. 

Lyrebird is a smart, clinician-first platform designed to help Australian general practices improve efficiency and care quality. It is exclusively integrated with Best Practice, meaning practices already using Bp Premier can access Lyrebird’s CCM workflow instantly—no setup, no retraining, and no disruption.

Here’s how it works:

• Natively integrated with Best Practice
  Lyrebird pulls and writes back directly to the patient record—no double handling or manual entry.
• One-click documentation
  Care plans are pre-filled with relevant history, ready for review and completion within a consult.
• No retraining required
  Lyrebird fits naturally into your existing workflow—so your team can keep focusing on patient care.
• Built-in review tracking
  Review reminders and tracking help ensure patients are followed up consistently every three months.

What to Do Next

1. Review your CDM workflow—are you ready for July 1?
2. Estimate your eligible patient base—it may be larger than expected.
3. Join our 30-minute webinar on July 9 to explore the changes in detail.
4. Book a demo to see how Lyrebird integrates with Best Practice and Cubiko.
5. Sign up to Lyrebird. Get Started.
6. Integrate Bp Premier with Lyrebird. Learn more.
7. Bookmark our dedicated resource hub to confidently navigate the CDM changes with Lyrebird.

Final Thoughts

This CCM transition is a meaningful step toward more consistent and inclusive chronic care. With the right systems in place, practices can confidently deliver better care to more patients—without overloading clinicians or losing time to paperwork.

As a Lyrebird user, you’re already ahead. Lyrebird is here to support that shift and ready to go come July 1. We’ve built tools to make this transition seamless, so you can stay focused on patients, not paperwork.