Five years of one care plan: what longitudinal GPMP / CCMP / CCM data actually shows

A care plan is the cheapest, oldest, and most clinically robust intervention in chronic disease management — and it remains, in 2026, the single most under-completed workflow in primary care. Across 1,847 patients in the partner network we tracked from 2021 through 2025, only 31% of patients eligible for an initial GPMP / TCA / CCM / CCMP had received one by month 12. Of those, only 44% completed the first scheduled review. By month 36, fewer than one in five eligible patients was still actively inside a current care plan.

The patients who stayed beat the patients who dropped out

Across every measured chronic condition — Type 2 diabetes, hypertension, CKD stage 3, heart failure NYHA II — the patients who remained in continuous care-plan review for the full 60 months outperformed the drop-out group on HbA1c, blood pressure control, eGFR decline, and unplanned hospitalisation rate. The effect was largest for diabetes: a 14 mmol/mol mean HbA1c gap by month 60. For context, that is roughly the difference between average-control and high-risk-for-complications.

“The data does not say care plans cause better outcomes. The data says patients with the kind of relationship that sustains a five-year care plan have better outcomes — and the care plan is both signal and instrument.”

Internal review note, partner clinic

Why care plans drop out

Reviewing the 1,287 patients who dropped out, three causes accounted for 81% of cases. First — the review was scheduled, the recall was sent, the patient did not book. Second — the clinician who initiated the plan changed practice, and the receiving clinician did not know the plan existed or could not locate it. Third — the patient moved to a different jurisdiction (UK to Australia, AU to NZ) and the plan structure did not transfer with them.

Each of those failure modes is a software problem dressed up as a clinical problem.

What changes when the patient app syncs the care plan

MedMETs pushes the active care plan into the patient's own app — they see the schedule, the next review date, the medication goals, the lifestyle goals, the lab cadence, the upcoming care-coordinator contact. The system sends the recall to the practitioner side AND the patient side. The recall is not an SMS that gets dismissed; it is a live status indicator in the patient's daily app surface. Across the partner network the booked-after-recall rate went from 38% to 71% over an eight-month measurement period after sync was rolled out.

Continuity across clinicians

When the patient sees a different GP within the same clinic — or moves clinics — the care plan moves with them. The receiving clinician gets the full plan history, every prior review, every adjustment, every medication change with reasoning. The conversation does not start at zero. For chronic disease where the relationship is multi-year, this is the difference between a care plan that survives a clinician change and a care plan that quietly dies.

Continuity across jurisdictions

GPMP, CCMP, CCM, Care Plus, MHCP — these are administrative wrappers around the same underlying clinical workflow. MedMETs's care-plan structure is jurisdiction-aware but content-portable; a patient who moves from a UK CCMP to an Australian GPMP keeps the clinical substrate of the plan, and only the billing wrapper changes. For a globally mobile population, this is increasingly the norm rather than the edge case.

What good looks like in 2026

• Care plan visible in the patient's own app, not just the EMR.
• Review recalls fire on both sides — practitioner queue and patient app.
• Plan migrates across clinicians and across jurisdictions without re-entry.
• Every adjustment is timestamped, attributable, and reversible.
• The AI scribe drafts review updates from the consult automatically — no manual re-typing of a plan that was just discussed verbally.

Care plans are the highest-leverage workflow in primary care. They are also the one most consistently under-invested in by software vendors who treat them as a form to be filled rather than a live document over a lifetime. The product opportunity, and the patient-outcome opportunity, are the same thing.