Measure 4.6. Increased number of people living with dementia with a chronic disease management plan in place with their GP
A number of chronic diseases, including diabetes and hypertension, are associated with the development of dementia. Dementia itself is a chronic condition and impacts of its progression can potentially be slowed through ongoing management, such as leading a healthy lifestyle, accessing medications subsidised through the Pharmaceutical Benefits Scheme (PBS), managing co-existing conditions and accessing allied health therapies to maintain function (AIHW 2025). Chronic disease management services on the Medicare Benefits Schedule (MBS) relate to the preparation, coordination and review of a GP Management Plan or Team Care Arrangements, or the contribution to a Multidisciplinary Care Plan for patients with a chronic or terminal medical condition, to help ensure they receive structured and coordinated care that will help them to achieve their current health goals.
Data are available from the National Health Data Hub (NHDH) to track this measure.
The indicator shown below should be interpreted with caution as NHDH data may not be nationally representative of all people living with dementia across Australia. It is important to note that Chronic Disease Management Plans are not the only way GPs manage chronic disease among their patients. This indicator will be complemented by other data if they become available.
-
Indicator
Proportion of the National Health Data Hub (NHDH) dementia cohort who had a Chronic Disease Management attendance.
-
Baseline value
48% of dementia cohort in 2021–22
-
Latest value
Baseline value only
-
Progress
To be provided in future updates
The desired outcome is that the proportion of the NHDH dementia cohort who had a Chronic Disease Management attendance will increase.
Change over time
Future updates of this report will track changes over time for this indicator.
Historical change over time: 2018–19 to 2021–22
Between 2018–19 and 2021–22, the proportion of the NHDH dementia cohort who had a Chronic Disease Management Plan attendance remained steady at 48% to 50% (Figure 4.6.1).
Figure 4.6.1: Proportion of the NHDH dementia cohort who had a Chronic Disease Management Plan attendance, 2018–19 to 2021–22
A column graph showing the proportion of people with dementia who had a Chronic Disease Management Plan attendance was highest in 2020–21 (50%) and lowest in 2021–22 (48%).
| Financial year | Proportion of dementia cohort |
|---|---|
| 2018–19 | 49% |
| 2019–20 | 49% |
| 2020–21 | 50% |
| 2021–22 | 48% |
Notes:
- Participants missing age information were excluded from the NHDH cohort.
- Participants with missing remoteness area or socioeconomic area are included in the NHDH cohort.
Source:
AIHW NHDH 2021-22, analysis of NHDH
The proportion of the NHDH dementia cohort who had a Chronic Disease Management Plan attendance in 2021–22:
- was relatively similar for males and females (49% and 48%, respectively)
- increased with age from 41% among people aged under 65 to 51% among people aged 75–84 years. The proportion then decreased in the older age groups (38% of people aged 95 and over)
- was slightly higher among people living in the community than those in residential aged care (50% and 47%, respectively)
- decreased with increasing remoteness, from 50% among people in Major cities to 32% among those in Very remote areas).
There were no clear patterns of variation by socioeconomic area.
These data come from AIHW analysis of linked health and aged care services data in the National Health Data Hub (NHDH 2021–22).
The NHDH is a longitudinal, person-focused, de-identified health linkage system, that comprises data from state and territory, Commonwealth and non-government data sources. As of August 2025, data in the NHDH spanned from 1 January 1997 to 30 June 2024, bringing together core government administrative health, welfare, disability and aged care datasets.
This indicator includes persons identified with dementia using data from admitted patient care, emergency department presentations, the Pharmaceutical Benefits Scheme, the National Death Index, and aged care assessments. As such, NHDH data may not be representative of all people living with dementia across Australia, with some people not accessing services offered by the included NHDH data sources.
Although some datasets spanned until the end of the 2023–24 financial year at the time of analysis, National Screening Assessment Form data were only available from 1 July 2015 to 30 June 2022. To ensure a consistent lookback period for identifying people with dementia across financial years, the most recent year of reporting was 2021–22.
Remoteness area is classified according to the Australian Statistical Geography Standard (ASGS) Remoteness Structure.
Data for population groups are reported for this most recent year of data only and where data quality allows.
For more detailed data, including the counts used to calculate proportions, see the Supplementary data tables.
For more information on the NHDH data and coding rules used in the analysis, see the Technical notes.
AIHW (Australian Institute of Health and Welfare) (2021–22) National Health Data Hub, aihw.gov.au, accessed 5 August 2025.
AIHW (2025) Dementia in Australia, AIHW, Australian Government, accessed 23 September 2025.