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Chronic Disease Management

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Chronic disease management plans form part of our commitment to the health of our local community. Our GPs can provide management plans for patients who suffer with a chronic medical condition.

Chronic Medical Conditions

A chronic medical condition is one that has been present for at least six months or longer, such as:

  • Asthma
  • Cancer
  • Cardiovascular disease
  • Diabetes
  • Musculoskeletal conditions
  • Stroke

Chronic Disease Management

Chronic Disease Management

Chronic Disease Management Plans

Chronic disease management plans are designed by general practitioners for patients who have complex conditions that require ongoing care and a structured approach.

A GP Management Plan (GPMP) can help people with chronic medical conditions by providing an organised approach to care. A GPMP is a plan of action you have agreed with your GP.

This plan identifies your health and care needs, sets out the services to be provided by your GP, and lists the actions you can take to help manage your condition.

Book an appointment with us today!

Nothing is more important to us than your health and comfort. We strive to provide quality and care to every member of the community.

Team Care Arrangements

If you have a chronic medical condition and complex care needs requiring multidisciplinary care, your GP may also develop Team Care Arrangements (TCAs). These will help coordinate more effectively the care you need from your GP and other health or care providers.

TCAs require your GP to collaborate with at least two other health or care providers who will give ongoing treatment or services to you.

Let your GP or nurse know if there are aspects of your care that you do not want discussed with other healthcare providers.

Regular Reviews

Once a plan is in place, it should be regularly reviewed by your GP. This is an important part

Diabetic Risk Assessment

As part of our commitment to the health of our communities, our doctors can provide a type 2 diabetes risk assessment for patients who feel they may be at risk.

One of the largest contributors to ill health in Australia is type 2 diabetes.
Type 2 diabetes accounts for 92% of all diabetes cases. Diabetes is associated with complications. For example, increased risk of cardiovascular, eye and kidney disease.

The incidence of type 2 diabetes has more than doubled in the last 15 years.
Lifestyle risk factors can lead to the onset of type 2 diabetes. In particular, being overweight and obesity, physical inactivity, and poor diet can be prevented through lifestyle modification.

International evidence has shown that early lifestyle interventions in high-risk patients can reduce the incidence of type 2 diabetes by upto 58%.

We offer care plans to all eligible patients who suffer from a chronic illness with little or no cost to the patient.

Patients are asked to book an appointment with their GP to determine if they are eligible. Our practice nurse will provide support and monitoring between visits to your GP. For more information about chronic disease management, please contact us or book an appointment online.

Diabetes Evaluation

If you would like to ascertain your risk of type 2 diabetes, you may wish to have a diabetes evaluation at our practice. In addition, you can complete the online risk assessment tool.

The diabetes evaluation will be provided with the assistance of our chronic disease nurse with your general practitioner.

The evaluation will involve:

  • Assessment of lifestyle risk factors
  • Body Mass Index measurement, blood pressure and general physical exam, and
  • Family history review

In summary, for a diabetes risk assessment, please contact us.