Count of regular clients who are Indigenous, have a chronic disease and for whom a GP Management Plan (MBS Item 721) was claimed within the previous 24 months.

‘Regular client’ refers to a client of an Australian Government Department of Health-funded primary health-care service (that is required to report against the Indigenous primary health care key performance indicators) who has an active medical record; that is, a client who has attended the Department of Health-funded primary health-care service at least 3 times in 2 years.

GP Management Plan (MBS Item 721): The Chronic Disease Management (CDM) Medicare items on the Medicare Benefits Schedule (MBS) enable GPs to plan and coordinate the health care of patients with chronic or terminal medical conditions (DoH 2016). GP Management Plans, for the purpose of this indicator, are defined in the MBS (Item 721).

Services taking part in the Health Care Homes Trial: For the duration of the Health Care Homes trial (currently 1 October 2017 to 30 November 2019), clients who are part of the trial will be deemed to have had an MBS Item 721 claimed if there is evidence of a GP Management Plan recorded.

Presented as a number.

Calculated separately for each chronic disease type:

a) Type II diabetes

Exclude Type I diabetes, secondary diabetes, gestational diabetes mellitus (GDM), previous GDM, impaired fasting glucose, impaired glucose tolerance.

b) Cardiovascular disease

c) Chronic obstructive pulmonary disease

d) Chronic kidney disease

At this stage, this indicator is only calculated for Type II diabetes as currently this is the only relevant chronic disease type with an agreed national definition.

Numerator only

Calculation A: Number of regular clients who are Indigenous, have Type II diabetes and for whom a GP Management Plan (MBS Item 721) was claimed within the previous 24 months.

1. Sex:
a) Male
b) Female

2. Age group:
a) 0–4 years
b) 5–14 years
c) 15–24 years
d) 25–34 years
e) 35–44 years
f) 45–54 years
g) 55–64 years
h) 65 years and over

This indicator covers a 24 month reporting period from 1 January 2020 to 31 December 2021:

• Indigenous primary health care NBEDS 2019–20 covers the period 01/01/2020 to 30/06/2020
• Indigenous primary health care NBEDS 2020–21 covers the period 01/07/2020 to 30/06/2021
• Indigenous primary health care NBEDS 2021–22 (to be released) will cover the period 01/07/2021 to 31/12/2021.

N[N(6)]

Further work is required to reach agreement on national definitions for other chronic diseases including cardiovascular disease, chronic obstructive pulmonary disease and chronic kidney disease.

Australian Institute of Health and Welfare

Australian Government Department of Health

DoH (Australian Government Department of Health) 2016. Chronic Disease Management—Provider information. Canberra: DoH. Viewed 12 February 2018, http://www.health.gov.au/internet/main/publishing.nsf/
Content/mbsprimarycare-factsheet-chronicdisease.htm.