Chronic Condition Management Plan
Ongoing Support for Long-Term Health Conditions
Managing a chronic health condition can be a life-altering challenge that will continue on. However, when you’re with the right people and professionals, you will be supported and heard. This is what our GPs and team members offer at Bomaderry Creek Health Centre.
Through our chronic condition management plan services, we help individuals live well while managing multiple chronic conditions. Our personalised, patient-focused approach allows us to tailor care plans that support both your current needs and long-term health goals.
As a trusted provider of chronic condition management programs in Bomaderry, we focus on early intervention, symptom monitoring, and coordinated care to improve your quality of life.
What Our Chronic Condition Management Plan Services Involve
Bomaderry Creek Healthcare Centre provides coordinated care for individuals with ongoing health conditions. Our services are guided by current clinical recommendations and delivered with a patient-centred focus.
Personalised Care Plans
Every patient case is different, thus, they may require different needs. Creating customised treatment plans ensures your medication management, lifestyle changes and goals are made specifically for your situation.
Collaborative Support and Monitoring
Our team can also work alongside you, your GP, and other healthcare providers to monitor your condition and adjust your care plan when needed. Regular follow-ups are a key part of our chronic conditions management approach, helping you stay engaged and informed throughout your health journey.
Common Conditions Our Team Can Support
Our chronic condition management service assists with a range of long-term health conditions, including:
- Diabetes
- Heart disease
- Asthma and emphysema
- Arthritis
- High blood pressure
- Kidney disease
- Osteoporosis
- Sleep apnoea
- Depression and anxiety
- Cancer (ongoing care coordination)
Why Choose Our Chronic Condition Management Plan Clinic in Bomaderry?
Our team at Bomaderry Creek Health Centre is committed to delivering care that’s local, accessible, and focused on the whole person. Being proactive and collaborative is our approach to the management of chronic conditions of any individual that ensures to support both physical and mental well-being.
Patients that are part of our chronic condition management plan clinic will have access to a caring team that values your input and keeps your health goals at the centre of your care plan.
Stay on Track with Your Health
Managing multiple chronic conditions does not have to feel like an uphill battle. With the right care and support from a skilled and experienced medical team, you can better manage your health and improve your day-to-day wellbeing.
Contact Bomaderry Creek Health Centre today to book an appointment or learn more about our Chronic Condition Management Plan.
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.