Chronic Condition Management Plan
Chronic disease management in Bomaderry supports patients living with long-term or complex health conditions through regular GP care, structured care planning, ongoing reviews, and allied health coordination where appropriate.
Managing a chronic condition often involves more than one appointment. It may require regular monitoring, a structured plan, practical lifestyle support, and coordinated care over time. Ongoing GP support can help patients better understand their condition, stay on top of treatment, and plan the next steps in their care.
What Chronic Disease Management Includes
Ongoing GP care for long-term health conditions
Chronic disease management involves structured GP care for conditions that need ongoing monitoring and support.
Depending on your needs, this may include:
- review of your current health and medical history
- monitoring symptoms and progress over time
- managing medicines and treatment plans
- preventive care and lifestyle advice
- referrals to allied health providers
- regular review appointments and follow-up care
This kind of care helps patients understand that chronic condition support is an ongoing process rather than a one-off consultation.
Conditions We Commonly Support
Care for a range of ongoing health concerns
Chronic disease management may support patients living with:
- diabetes
- asthma and other respiratory conditions
- heart disease and high blood pressure
- arthritis and musculoskeletal conditions
- kidney disease
- osteoporosis
- sleep apnoea
- depression, anxiety, and other long-term health concerns
- other chronic or complex conditions requiring ongoing care
Having ongoing support for these conditions can help patients better manage day-to-day health needs and reduce the risk of complications over time.
Care Plans, Team Care Arrangements, and Medicare
Structured support for eligible patients
For some patients, chronic disease management may include a written care plan developed with a GP. Where appropriate, this may also involve a Team Care Arrangement to help coordinate care with allied health providers or other healthcare professionals.
Some services may attract Medicare rebates for eligible patients, depending on the plan and the services involved. Eligibility and rebates can vary, so it is important to discuss your individual circumstances during your appointment.
How Chronic Disease Management Works
What to expect from your care
Chronic disease management is usually based on your individual condition, symptoms, and ongoing healthcare needs.
1. Initial GP appointment
Your GP reviews your condition, current treatment, medicines, and overall health needs.
2. Care planning
If appropriate, a care plan may be prepared to support your long-term management and set practical health goals.
3. Coordinated support
Where needed, your GP may recommend allied health services or referrals to help support your care.
4. Ongoing reviews
Regular follow-up appointments may be used to monitor your progress, review your plan, and adjust your care where needed.
Care Plans, Team Care Arrangements, and Medicare
Structured support for eligible patients
For some patients, chronic disease management may include a written care plan developed with a GP. Where appropriate, this may also involve a Team Care Arrangement to help coordinate care with allied health providers or other healthcare professionals.
Some services may attract Medicare rebates for eligible patients, depending on the plan and the services involved. Eligibility and rebates can vary, so it is important to discuss your individual circumstances during your appointment.
How Chronic Disease Management Works
What to expect from your care
Chronic disease management is usually based on your individual condition, symptoms, and ongoing healthcare needs.
1. Initial GP appointment
Your GP reviews your condition, current treatment, medicines, and overall health needs.
2. Care planning
If appropriate, a care plan may be prepared to support your long-term management and set practical health goals.
3. Coordinated support
Where needed, your GP may recommend allied health services or referrals to help support your care.
4. Ongoing reviews
Regular follow-up appointments may be used to monitor your progress, review your plan, and adjust your care where needed.
Book a chronic disease management appointment in Bomaderry
If you are living with a long-term or complex health condition, ongoing GP support can help you manage your health more effectively over time.
Chronic disease management in Bomaderry can provide practical support, regular reviews, and coordinated care where needed.
Book online or contact the clinic to arrange an appointment.
Frequently Asked Questions
What is Chronic Condition Management Plan?
Chronic Condition Management Plan is ongoing, team-based care to help you manage long-term conditions (e.g., diabetes, heart or lung disease, arthritis) with clear goals and regular reviews.
Who is eligible for a Chronic Condition Management Plan?
People with a chronic or complex condition that’s been present (or is likely to be present) for six months or more. Your GP will confirm eligibility.
What is a Chronic Condition Management Plan (care plan)?
It’s a written plan made with your GP that outlines your health goals, treatments, medicines, and supports. It helps everyone stay on the same page.
What is a Team Care Arrangement (TCA)?
A TCA is added when you need coordinated care from at least two other providers (e.g., dietitian, physio, podiatrist). It sets roles and follow-up actions.
Are there Medicare rebates for Chronic Condition Management Plan?
Medicare rebates may apply for the GP plan and, if eligible, for referred allied health visits under a TCA. We’ll explain any out-of-pocket costs before you proceed.
What happens in a Chronic Condition Management Plan appointment?
Your GP reviews your history, medicines, recent tests and symptoms, sets goals with you, and may arrange referrals, care coordination and monitoring.
How often is my plan reviewed?
Plans are usually reviewed every 3–6 months, or sooner if your condition, medicines, or goals change.
Can allied health be included in my plan?
Yes. If clinically appropriate, your GP can refer you to allied health (e.g., diabetes education, exercise physiology, psychology) as part of your plan.
Do I need to bring anything?
Bring your Medicare card, a current medicines/supplements list, home readings (e.g., BP, blood glucose), recent test results, and any questions you want to discuss.
Is my information shared with other providers?
With your consent, relevant details can be shared with your care team and uploaded to My Health Record to support safe, coordinated care.