Chronic Disease Management

Providing a comprehensive general practice service.

What is a Chronic Disease Management Plan?

If you have a chronic medical condition, you may be eligible for a GP Management Plan (GPMP). This is a plan developed between you and your GP, usually with the assistance of our nurse.

Why do you need this?

This will inform you on the support services that you may be eligible to receive. Working with a Team to manage your disease and provide access to enable you to reach your health goals.

What are the steps involved?

Your GP, with the assistance of the Practice Nurse will collaborate with you to:

Assess your particular health care needs
Agree to achievable management goals for better health out comes
Identify action to be taken and identify treatment & services that may help
Develop a plan outlining all of the above
Arrange ongoing review of goals and management as set out in the plan
Agree to achievable management goals for better health out comes
Develop a plan outlining all of the above
Arrange ongoing review of goals and management as set out in the plan

Team Care Arrangement (TCA)

Patients on a plan often benefit from a team of health professionals and support services that can be included to manage their complex health needs.
If identified as beneficial for you, the ‘team’ which will include your GP and at lest two other health providers, will aim to help you reach your health goals. This team to be included will be based on discussion with you and your individual health needs.

Examples of health services and providers who could provide ongoing health care/ support and be part of your ‘team’ are:

Your pharmacist
Meals on Wheels
District Nurse

Some may already be providing care and can be included in the team.

Allied Health Professional Referrals

Referral to Allied Health Professionals by the GP may often be identified as beneficial during the preparation of the GPMP. These health professionals can become an important part of the ‘team’ that assists you to reach your health goals.
Medicare rebates are available to assist with up to 5 Allied Health visits each year.

This may include visits to an:

Aboriginal Health Worker,
Audiologist,
Chiropractor,
Diabetes Educator,
Dietitian,
Exercise Physiologist,
Mental Health Worker,
Occupational Therapist,
Osteopath,
Physiotherapist,
Podiatrist,
Psychologist
Speech Pathologist.

Are there any costs involved?

Most costs for any of the services described are covered by Medicare. However in some cases you may be charged a gap fee. Where possible, your Practice Nurse will provide you with information regarding gap charges.

What are the benefits?

Better health outcomes
Clearer goals
Improved self-management
Access to other professionals
Better team involvement
Better follow-up

Ask your GP or Practice Nurse about preparing a GP Management Plan and the services that could help to improve your health. You will need to have blood tests prior to having a care plan done so you should make an appointment to discuss whether you are eligible first.

To make an appointment with your GP or to talk to the Practice Nurse please contact us at Virginia on 8380 9145 or Heritage on 8520 2220.