Chronic Disease


For many years General Practitioners have been supported by the government to manage the health of people with chronic conditions by the provision of  specific Medicare item numbers to provide a coordinated approach to managing your health.

Chronic Disease and GP Managed Care Plans

Many patients live with a chronic disease – there is a lot that can be done to help you live with the best health outcomes possible.

What are some features of a chronic disease?

  • it lasts a long time
  • usually won’t go away by itself (and often can’t be cured completely)
  • may be quite complex
  • often takes a long time to develop (often from a number of risk factors)

What are some types of chronic disease?

  • Type 2 diabetes
  • Heart disease
  • Stroke
  • Asthma
  • Chronic obstructive pulmonary disease (COPD)
  • Chronic Kidney Disease
  • Depression
  • Cancer
  • Arthritis
  • Osteoporosis

It’s important for chronic conditions to be managed with the support and ongoing care of your independent GP.  While some conditions may not have a very positive outlook, many can be managed to achieve improved health outcomes.

How can I manage my chronic condition?

The best place to start is to build an ongoing partnership with your independent GP.  In managing your condition together, over time, you will improve your chances of better health outcomes.   Another important part of the independent practitioner’s work is to ensure you have sound, factual information to help you understand your particular health issues.

A Medicare General Practice Management Plan (GPMP) is also used to help people manage their chronic disease.  This is a care plan which identifies all your health and welfare needs and the services needed to address them.

Importantly, things you can do for yourself are also identified in the plan.  This is known as “self-management” – a key factor in managing chronic conditions and improving health outcomes.

Our nurses often assist you and your independent GP to develop your GPMP.  We provide a longer appointment with the nurse – this dedicates time to identify your personal health needs and create the best care plan for you.   In the last part of this appointment, your independent GP will join you to complete the plan and sign it off.  This plan will guide you and your independent GP in the management of your condition over time.  Any services or referrals you need will also be arranged at this time.

Additionally, patients who require the ongoing input of at least two services providers (in addition to the independent GP) may be eligible for the Medicare Team Care Arrangement (TCA).  This is a multidisciplinary care plan. When a number of people are involved in your care, it is often useful to have a plan that identifies everyone and what their roles are.  This helps coordinate your ongoing care.

Please discuss these services with your independent Doctor or the nurse – they aim to work with you in order to help you achieve the best health outcomes possible.