Chronic and complex care, teams and transitions
Multimorbidity in Australia, the 2025 GP chronic condition management plans, NDIS and aged care entry rules, cost and access, multidisciplinary goal setting, safe handover and transitions, and how risk registers, HACs and open disclosure manage system-level harm.
Tier 1Topic overview
Written with AI assistance and fact-checked against the sources below. For exam study, not clinical decisions. How notes are made
At a glance
- In the 2022 National Health Survey, 38% of Australians had two or more of 72 long-term conditions (AIHW), rising to 79% of those aged 85 and over. Guidelines are written for single diseases; your patients rarely have one.
- Good chronic care is coordinated (one plan, one lead), goal-directed (what matters to the patient), affordable and continuous across settings.
- Most harm in complex care happens at transitions: admission, discharge, ward transfer, handover and the move from paediatric to adult services.
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Sources
- NSQHS Standards (second edition, 2021 version): Partnering with Consumers, Medication Safety and Communicating for Safety standardsAU/NZAustralian Commission on Safety and Quality in Health Care, 2021
- NSQHS Standards third edition engagement hub (third edition in development)AU/NZAustralian Commission on Safety and Quality in Health Care, 2026
- Australian Sentinel Events List (version 2)AU/NZAustralian Commission on Safety and Quality in Health Care, Version 2
- Australian Charter of Healthcare Rights (second edition)AU/NZAustralian Commission on Safety and Quality in Health Care, 2019
- Australian Open Disclosure Framework 2026AU/NZAustralian Commission on Safety and Quality in Health Care, 2026 (released June 2026)
- Upcoming changes to the chronic disease management framework: GP chronic condition management plans (from 1 July 2025)AU/NZAustralian Government Department of Health, Disability and Ageing (MBS Online), 2025
- Upcoming changes to chronic disease management MBS items: transition arrangements for existing patientsAU/NZAustralian Government Department of Health, Disability and Ageing (MBS Online), 2025
- Support at Home program (replaced Home Care Packages and Short-Term Restorative Care on 1 November 2025 under the Aged Care Act 2024)AU/NZAustralian Government Department of Health, Disability and Ageing, 2025
- PBS patient fees and charges (general co-payment $25 from 1 January 2026)AU/NZPharmaceutical Benefits Scheme, 2026
- Multimorbidity in Australia (2022 National Health Survey data)AU/NZAustralian Institute of Health and Welfare, 2025
- Last updated
- 14 November 2026
What changed
- 14 November 2026 Personal emails, About story and Australian-style copy