Recipe Name:

Identify all patients with a chronic disease eligible for a GP Management Plan and/or Team Care Arrangement who haven't had a claim in the last 12 months


The Chronic Disease Management — GP services on the Medicare Benefits Schedule (MBS) enable GPs to plan and coordinate the health care of patients with chronic or terminal medical conditions, including patients with these conditions who require multidisciplinary, team-based care from a GP and at least two other health or care providers. 


To effectively manage the care of patients with a chronic disease.

CAT Starting Point:

  1. CAT Open - CAT4 view (all reports) loaded
  2. Population Extract Loaded and Extract Pane “Hidden”
    1. Filter Pane open and under the ‘General’ tab ‘Active Patients’ (3x <2 years) selected (this step can be
       omitted if you want to search for all patients).

Filter Steps

  • Under the 'Conditions' tab, choose the 'Chronic' tab, and then select Yes under the Diabetes section

  • Under the 'Date Range (Results)' tab, choose <=12 months, then click 'Recalculate'

Recipe Steps Reports

  • Hide Filters
  • Select the "MBS Items" tab
  • Select the "Not Recorded" tab
  • Select the column titled "721 (CDM-GPMP)", and click the Export button in the top right hand corner
  • Repeat the step for the column titled "723 (CDM-TCA)".


This report will show all patients with a coded diagnosis of diabetes who haven't had a GP Management Plan or Team Care Arrangement billed in the past 12 months. 


This recipe shows the steps to view a list of patients with diabetes who haven't had a GP Management Plan or Team Care Arrangement billed in the previous 12 months. This recipe can be modified for patients with any other chronic disease by choosing a different chronic condition under the Conditions, then Chronic filter tab (as shown in the second screenshot above). Other chronic conditions that may be targeted include, but are not limited to:

  • COPD
  • Asthma
  • Hypertension
  • Cardiovascular Disease
  • Chronic Kidney Disease

To Export Patient List to Microsoft Excel:

1.  Click on the “Export Icon”  at the top of the Patient Reidentification window.

2.  Click on “Excel”

3.   Choose a file name and a location to save to (eg. Create a folder C:/ClinicalAudit/CAT Patient FollowUp)

4.  Click “Save”

The steps above will produce a list of patients with contact details in MS Excel which can then be used to:

1.   Go back through the individual patient records in the GP Clinical Desktop System (CDS) and update known records

2.  Phone patients to update their record

3.  Produce a mail merge to recall patients for follow up