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. From 1 November 2026, plans and reviews can also be done by phone for existing patients, where your GP considers it suitable.
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 and Medicare
Structured support for eligible patients
For some patients, chronic disease management includes a written GP chronic condition management plan developed with your GP. Where appropriate, your GP can also refer you to allied health providers or other healthcare professionals as part of your plan.
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.
Phone Appointments for Plans and Reviews
From 1 November 2026, our GPs can prepare or review your plan by phone. Phone appointments are available to existing patients, and your GP will decide whether a phone appointment suits you. Some visits still need to happen in person, for example when an examination or test is needed.
Call our reception team on (02) 4413 2325 to book a phone 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.
Ongoing Support for Better Day-to-Day Management
Living with a chronic condition often means your healthcare needs can change over time. Regular GP support can help track symptoms, review medicines, respond to changes in your health, and keep your care on track.
This may include:
- Reviewing symptoms and health changes
- Monitoring medicine use and treatment plans
- Updating your care plan where needed
- Discussing prevention and lifestyle factors
- Coordinating follow-up care with other providers
Why Patients Choose BCHC for Chronic Disease Management
- Ongoing GP care for chronic and complex conditions
- Support with care plans and regular reviews
- Team-based coordination where appropriate
- A local clinic in Bomaderry
- Practical follow-up care over time
- Online booking and convenient access
Chronic Disease Management Near Bomaderry
Bomaderry Creek Health Centre supports patients in Bomaderry and nearby areas, including North Nowra, Nowra, Meroo Meadow, Terara, and Cambewarra. If you are looking for a GP clinic that offers ongoing support for chronic or complex health conditions, our team is here to help.
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 happened to the GP Management Plan and Team Care Arrangement?
Since 1 July 2025, one GP chronic condition management plan has replaced both. If your GP thinks you would benefit from multidisciplinary care, they can refer you to allied health providers as part of your plan.
Are there Medicare rebates for Chronic Condition Management Plan?
Medicare rebates may apply for the plan and, if eligible, for up to five referred allied health visits per calendar year. Fees for allied health visits can vary between providers, so please check when you book.
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?
Your GP can review your plan every 3 months if clinically needed, or sooner if your condition, medicines or goals change. To keep Medicare access to allied health, your plan should be prepared or reviewed within the last 18 months.
Can I have a care plan appointment by phone?
Yes, from 1 November 2026 our GPs can prepare and review plans by phone for existing patients. Your GP will decide whether a phone appointment suits you, and some visits may still need to be in person. Call reception on (02) 4413 2325 to ask what’s right for you.
Are care plans and reviews bulk billed?
Yes. Bomaderry Creek Health Centre bulk-bills all services except procedures such as iron infusions and private medicals. This includes care plans and reviews, by phone or in person.
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.