Chronic Disease Management

What is a chronic medical condition?

A chronic medical condition is one that has been (or is likely to be) present for six months or longer, for example, asthma, cancer, heart disease, diabetes, arthritis and stroke. There is no list of eligible conditions. However, these items are designed for patients who require a structured approach and to enable GPs to plan and coordinate the care of patients with complex conditions requiring ongoing care from a multidisciplinary care team. Your GP will determine whether a plan is appropriate for you.

GP Management Plan

A GP Management Plan (GPMP) can help people with chronic medical conditions by providing an organised approach to care. A GPMP is a plan of action you have agreed with your GP.

This plan:

• identifies your health and care needs;
• sets out the services to be provided by your GP; and
• lists the actions you can take to help manage your condition.

Team Care Arrangements

If you have a chronic medical condition and complex care needs requiring multidisciplinary care, your GP may also develop Team Care Arrangements (TCAs). These will help coordinate more effectively the care you need from your GP and other health or care providers. TCAs require your GP to collaborate with at least two other health or care providers who will give ongoing treatment or services to you. Let your GP or nurse know if there are aspects of your care that you do not want to be discussed with other healthcare providers.

If you have both a GPMP and TCAs prepared for you by your GP, you may be eligible for Medicare rebates for specific individual allied health services that your GP has identified as part of your care. The need for these services must be directly related to your chronic medical (or terminal) condition. If you have type 2 diabetes and your GP has prepared a GPMP, you can also be referred for certain allied health services provided in a group setting.

If a provider accepts the Medicare benefit as full payment for the service, there will be no out-of-pocket cost. If not, you will have to pay the difference between the fee charged and the Medicare rebate.

Regular review of your care plan

Once a plan is in place, it should be regularly reviewed by your GP. This is an important part of the planning cycle, where you and your GP check that your goals are being met and agree on any changes that might be needed. The practice nurse can provide support and monitoring between visits to your GP.

FOR CARE PLAN BOOKINGS, PLEASE CALL THE CLINIC DIRECTLY.