Chronic disease management

A disease or condition is considered chronic when it has been present for six months or more. It includes conditions such as diabetes, osteoarthritis, asthma, cancer and heart disease.

Living with a chronic disease can affect many aspects of your life. We work closely with you, your loved ones and your general practitioner (GP) to help you manage your condition.

While chronic diseases progress in different ways, they often develop over a long time and are resistant to treatment. A long term management plan is often necessary.

Chronic disease management services

A Chronic Disease Management Plan provides support from a range of medical and allied health services, including:

physician consultation
diabetes education
nutrition advice from a qualified dietitian
support, counselling and information about community resources from a social worker
a personalised exercise program developed by a physiotherapist
an occupational therapist, who can assist you maintain your independence in daily activities.

If you have a chronic medical condition, you may be eligible for Medicare benefits if your doctor prepares the following plans for you.

GP Management Plan

A GP Management Plan can help if you have a chronic or terminal medical condition by providing a clear approach to your care. It is a plan of action agreed between you and your GP. It identifies your healthcare needs, sets out the services to be provided by your GP and others and lists the actions you need to take.

Team Care Arrangements Plan

If you need treatment from two or more health professionals, your doctor may also put a Team Care Arrangements Plan in place for you. This lets your doctor work with, and refer you to, at least two other health professionals who will provide your treatment or services.

Benefits of a Chronic Disease Management Plan

A Chronic Disease Management Plan has a number of benefits. It can:

improve your exercise tolerance
improve your activity levels and function
give you the skills and education you need to take care of your own health
allow you to enjoy better quality of life.

These benefits depend on your particular circumstances and require you to fully participate in necessary before and after care and management. You should consult a specialist in this area before deciding whether treatment is suitable for you.

Referrals

Patients may be referred directly to us using our referral form:

Rehabilitation referral form