Chronic Condition Management (CCM) for Indigenous health

There are Chronic Condition Management (CCM) services for managing Indigenous patients with a chronic or terminal condition.

If you’re their usual treating practitioner, find out how to create and manage a Chronic Condition Management (CCM) plan for your Indigenous patient.

Certain health professionals can help eligible practitioners deliver some services for Indigenous patients, including both:

  • CCM plan development
  • monitoring and support services.

Health professionals who can help include:

  • practice nurses
  • Aboriginal and Torres Strait Islander health practitioners
  • Aboriginal health workers.

They can help to prepare, contribute and review CCM items, including all of the following:

  • collecting information
  • supporting collaboration with a multidisciplinary team
  • providing relevant information to the patient.

Medicare item requirements must be met, including all of the following:

  • reviewing and confirming assessments
  • seeing the patient.

Certain health professionals can deliver monitoring and support services Medicare Benefits Schedule (MBS) items 10997, 93201 and 93203.

Health professionals who can provide monitoring and support services include:

  • practice nurses
  • Aboriginal and Torres Strait Islander health practitioners.

They may provide up to 5 services per calendar year for a patient who has a current CCM plan. The service must be both:

  • provided on behalf of and under the supervision of the eligible practitioner
  • consistent with the patient’s CCM plan.
Page last updated: 1 July 2025.
QC 74185