How to kickstart your CDM Program for 2022

by | What We're Talking About

With 1 in 3 Australians diagnosed with a chronic condition, Chronic Disease Management (CDM) has become a vital component of the care provided in General Practice. An estimated $60 billion is spent annually caring for patients diagnosed with chronic conditions.

Not only does CDM play a vital role in the continued care of these patients. But it also provides practices with the opportunity to billings so that they can continue providing excellent patient care.

The initial impacts of the COVID-19 pandemic quickly transformed how practices operated. We saw practices quickly adapting to the new COVID-19 world of lockdowns and vaccine rollouts, resulting in core business, such as their CDM programs, being put on the back burner.

While we are not entirely out of the woods, we have seen practices slowly shift their focus back to core business and care such as their CDM program.  We ask ourselves how practices can kickstart their CDM program in 2022?

This article acts as a guide to help you as we slowly move to a normalisation of COVID-19 vaccines as part of our everyday lives.

Using data to re-engage your patients

Patient engagement is key to the continued care of patients with chronic conditions. The last two years have proven to be difficult for General Practice. While many practices tried to stay on top of their routine work and CDM programs, the pandemic, lockdowns, and restrictions resulted in preventative health taking a backseat when presented with vaccinations.

Now that practices have weathered the storm and have systems in place to deal with the impacts of COVID-19. Along with the extension of Telehealth MBS item numbers, which can be used for CDM and preventative health, now is the time for clinics to re-engage with their patients. 

Utilising your practice data and having access to the right technologies can help make it easier to find those patients who may be eligible or overdue for a CDM service. Without these tools and technologies, extracting this data can be complex and time-consuming, requiring you to run custom scripts in your practice management system to pull the data.

Cubiko’s Item Optimisation feature provides you with the metrics and data to help you gain insight into the patients who may be eligible or overdue for these services. Provide these lists to your nursing team so that they can speak to your doctors to prioritise the patients who may be high risk or need care soonest. Your nursing team can then work through the list to engage with these patients and get them to book in for an appointment.

Another avenue you can take is involving your practitioners in the patient engagement for proactive patient care with our doctor direction sheet, which you can download here. Get your practitioners to fill out the direction sheet before the patient leaves the consult room to indicate what services they want the patient to booked in for next. 

Empower your CDM team

Running a successful CDM program requires a team and resources. Therefore, it’s vital that you look at your data to evaluate your practices availability and capacity to dedicate time to your CDM program.

Depending on how much time and resources you’re willing to dedicate towards getting back on top of or expanding your CDM program, you may consider growing your team. Look to your practice data to determine if it is financially viable for you to expand your team in an effort to grow your practice’s CDM program.

Once you have assembled the team dedicated to CDM in your practice, we use data and new initiatives to bring them along on the journey. Set goals and targets that empower your team and give them access to the data you’re tracking that’s relevant to them so they can be proactive, measure and stay accountable to these targets.

Incorporating CDM with vaccines

Managing the effects of the pandemic and the COVID-19 vaccine program has been a primary focus for General Practice over the last two years. However, as we look to kickstart CDM in 2022, we must look for opportunities to incorporate CDM into the care already being provided to patients.

Look to your patient data to identify patients to be recalled or with an upcoming vaccination appointment to see if they are eligible or overdue for a CDM service. Cubiko’s Vaccination Support and Item Optimisation features can help practices easily identify these patients. Download these lists for your reception or nursing team to contact to ensure these patients know they are due for a care plan. Then, ensuring that you’re booking them for an appointment where both services can be performed in the same setting. Incorporating your vaccinations and CDM appointment is completely dependent on how your practice prefers to operate. If you prefer keeping these appointments separate, we’d recommend utilising the doctor direction sheet to ensure patients are booked in for their next appointment.

After a long and difficult two years, it’s time that we get back to core business by kickstarting and optimising our CDM programs in 2022. If you’re interested in learning how Cubiko can help you optimise your CDM program book in for a demo today. 

For more information telephone 1300 CUBIKO (1300 282 456) or email