Care and management plans are being targeted as a compliance “focus area” for 2026— along with telehealth, claiming MBS services while overseas, inappropriate claiming of PBS medicines and open and uncertified PBS claims (where the supply of pharmaceutical benefits was not certified, and the claim closed).

The Department of Health, Disability and Ageing (DoHDA) released its compliance priorities last week, saying claims for care and management plans will be monitored “to better understand how we can support health provider compliance and ensure MBS sustainability.”

GPs overwhelmingly think the majority of care plans are achieving their intended goal for the patient, a Healthed survey with nearly 1400 respondents so far has found.

But Dr Chris Bollen, a GP and director of Bollen Health who consults in chronic disease management said requirements such as clearly documenting the patient’s chronic conditions and updating their goals when the plan is reviewed are crucial to improving outcomes—and these are sometimes missed.

Here are his practical tips to both stay compliant and support patients better.

Make sure you’re coding chronic conditions

“You’ve got to be really clear that this person actually has a chronic condition that’s been coded in the software. Because time and time again, at a departmental level, but also across practices that I do consulting work with, the nurses will tell me that patients are coming in for their care plan and there is not a chronic condition listed,” Dr Bollen says.

It’s often clear from the number of medications the patient is on that they do have chronic conditions, but the specific conditions aren’t listed, creating a challenge for other health professionals trying to create a relevant plan, he says.

“If we’re going to have team care, we all need to be able to see the notes, we all need to be able to look at the health summary and say, right, it’s quite clear that the person has these chronic conditions.”

It’s also a patient safety issue, he adds. Take chronic kidney disease for example.

“If I’m prescribing something – and the great example is Paxlovid for COVID – which has to have its dose reduced if a person has chronic kidney disease — the software will not flag that unless it has been coded.”

Dr Bollen says practice audits using software extraction tools to identify all patients with CKD stage 3 or worse (based on eGFR) have shown that for every one case that’s coded, four are not.

Is the condition eligible for a care plan?

There’s no longer a list of chronic conditions, but it’s important to have a clear diagnosis of a condition that lasts for over six months or is terminal – or an issue where it’s clearly documented that the person’s function has been impacted for more than six months, Dr Bollen says.

“Frailty is now recognised as a long-term condition. There was some discussion about whether if you’re living with frailty as an older person, whether that is something you should have a care plan for. Well, it clearly is now, because it impacts function,” he says.

Include the patient’s goals

Another place that many care plans will fall over on is a lack of documented patient goals, Dr Bollen adds.

“You need to have the patient’s goals, not just the doctor’s goals.”

“If you go back and look at the PSR documents over the last 10 years, this has been a recurrent theme, lack of attention to patient goals.”

“This has simply been seen as a tick box exercise to access an allied health professional, rather than how do we plan wellness for this person? What does this person with a chronic condition really need to be at their best over this next 12 months? What are the immunisations required? What are the other screening tests? What are the other blood tests? What else needs to be done to support this person to live well at home?”

Don’t just copy and paste from a previous plan

It’s important to actually update the plan when you review it – and make comments on the goals, Dr Bollen emphasises.

“Another pitfall is if you just simply copy and paste stuff, and you haven’t touched it to say, right, this person’s goal was she was going to walk two kilometres every three days, and the same goal keeps appearing and there’s no discussion about, well, did you achieve it? And why didn’t you achieve it? What happened? What got in the way of you achieving it? What can we do now to set the goal again? What can we do to help you overcome your barrier to that particular goal?”

While the admin can feel frustrating, Dr Bollen says there is strong evidence to support this, and keeping the patient’s goal front and centre is part of world-renowned models such as the Stanford Chronic Disease Self-Management Program and the Flinders Program.

Audit yourself

Doing your own audit and reporting back to a peer is a good way to find blind spots.

“I run audits across the country and it’s really interesting, when the doctors review whatever it is we’re auditing against the evidence that I’ve shown them, they go, oh, OK, I thought I was doing all those things, but clearly I’m not. Maybe only half the time do I do them.”

“It gets them thinking about why, and it comes back to their system.”

“All of these things which become quite clear when we’re working in a time poor, complex environment like general practice. You need checklists in order to make the right thing easy to do more of the time.”

Use checklists to support compliance
Dr Bollen recommends developing practice systems – in particular check lists to support doctors and nurses in creating care plans – rather than just relying on the software templates.

“We should have a much better system within our practices of discussing this and reviewing each others’ documents,” Dr Bollen says.

“The practice I work in, we’ve got a really good checklist that we talk about regularly. What needs to be added to it? So we’re not missing anything for the care of our patients, number one. And number two, when it comes to, if we were to be reviewed, we’ve all talked about what needs to be in the plan and we’ve got patient goals documented. So the nurses know, the doctors know. We have this constant conversation about it because in the end, it underpins a lot of what the work is done.”