OpenClaw for GP Clinics: Automating Chronic Care Plan Reviews and Health Assessments

OpenClaw for GP Clinics: Automating Chronic Disease Care Plan Reviews and Annual Health Assessments

In Australian general practice, Chronic Disease Management (CDM) plans and annual health assessments (MBS item numbers 721, 723, 701, 703) are both clinically valuable and administratively time-consuming. They require proactive identification of eligible patients, outreach to schedule appointments, preparation of review documentation, and follow-up to ensure the assessment actually happens.

In a busy GP clinic, this outreach often gets deprioritised in favour of acute presentations. OpenClaw automates the entire outreach and scheduling workflow, ensuring eligible patients are identified and contacted systematically — not whenever reception has a spare moment.

Setting Up OpenClaw for a GP Practice

```bash

curl -fsSL https://openclaw.ai/install.sh | bash

openclaw onboard --install-daemon

```

Connect WhatsApp for patient outreach and Slack for internal team coordination. Integrate with the practice's clinical software (Best Practice, MedicalDirector, Zedmed) via the reporting module to export eligible patient lists.

Identifying and Outreaching Eligible Patients

```

Skill: cdm-outreach

Schedule: 0 8 1 * * (first of each month)

Prompt: "Read the eligible patient export from this month's chronic disease management list. For each patient who has not had a CDM review in the last 10 months: send a WhatsApp message: 'Hi [Name], this is [Clinic Name]. Dr [Name]'s records show you are due for your annual chronic disease review — a special appointment to check in on your [diabetes/heart condition/asthma — from patient record] and review your care plan. These appointments are fully covered by Medicare with no out-of-pocket cost. Reply BOOK to have our team call you to schedule, or call us at [phone number]. This appointment helps keep your health on track all year.' Log who has been contacted and when."

```

Health Assessment Outreach (75+ Annual Health Assessment)

For patients aged 75 and over who are eligible for an annual health assessment:

```

Skill: health-assessment-outreach

Schedule: quarterly check on eligible patient list

Prompt: "For each patient aged 75+ who has not had an annual health assessment in the past 12 months, send a WhatsApp message (or SMS if WhatsApp not available): 'Hi [Name], this is [Clinic Name]. Dr [Name] would like to invite you for your annual health assessment — a special appointment for patients in your age group that helps us catch any health concerns early and plan ahead. This appointment is fully covered by Medicare. Would you or a family member like to book? Reply YES and our team will call to find a time that suits you.' Where a family carer is registered, also send them a notification."

```

Appointment Confirmation and Preparation

Once a review appointment is booked:

```

Skill: cdm-appointment-prep

Trigger: CDM appointment booked (webhook from scheduling system)

Prompt: "Send [Patient Name] a WhatsApp confirmation: 'Your annual health review with Dr [Name] is booked for [Date] at [Time]. To make the most of this appointment, please bring: (1) A list of all your current medications including anything you buy at the pharmacy without a prescription, (2) Your blood pressure diary if you keep one, (3) Your blood glucose records if you check at home, (4) Your glasses and hearing aids if you use them. We may need to do a blood test — it is best if you have not eaten for 4 hours before your appointment. Reply HELP if you have any questions.' Send a 48-hour reminder before the appointment."

```

Pre-Appointment Summary for GP

Before each CDM review appointment, OpenClaw pulls together a summary:

```

Skill: cdm-pre-appointment-brief

Schedule: runs 30 minutes before each CDM appointment

Prompt: "Generate a pre-appointment brief for Dr [Name]'s CDM review with [Patient Name]. From the patient's record summary provided, include: current active diagnoses, current medications, last recorded readings for relevant parameters (HbA1c, blood pressure, cholesterol, weight), preventive care items due or overdue (vaccination, cancer screening, eye review, foot check), and any outstanding referrals. Format as a one-page summary the GP can review in 90 seconds. Post to Slack DM to Dr [Name]."

```

Post-Review Task Follow-Through

After a CDM review, the GP orders investigations and referrals. OpenClaw tracks that these happen:

```

Skill: cdm-followup-tasks

Trigger: CDM review appointment marked complete (webhook)

Prompt: "From the post-review task list submitted by the GP, send [Patient Name] relevant follow-up reminders: 'Hi [Name], great to see you for your health review today. Here are your next steps: [list tasks — e.g., 'Book blood test at [pathology lab] — a referral has been sent', 'Book eye check — referral sent to [ophthalmologist]', 'Start new medication [X] as prescribed']. Please let us know if you need help booking any of these. We will check back with you in [4 weeks] to see how you are going.' Set reminder to check back at the specified interval."

```

What GP Clinics Report

GP clinics using OpenClaw for CDM outreach report:

The clinical quality of the review remains entirely the GP's. OpenClaw ensures the administrative scaffolding that makes the review possible is reliably in place.