GP Chronic Condition Management Plans are for any patient with a chronic condition. This is defined as a condition likely to last, or that has lasted, longer than 6 months.

A CCM involves you, the practice nurse, and your GP, who with your consent and assistance, form a written plan of management outlining your care. Your medical, physical, psychological, and social needs are all considered during the development of the plan. This is most beneficial for patients with long-term medical conditions that last longer than 6 months, such as diabetes, asthma, heart disease, arthritis, palliative care needs, etc.

Together with your doctor you will decide:
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What your health care problems and needs are
What results you would like to achieve through the plan
What other health care and community services are available for you

You will also be given a copy of the plan. If you would like a carer, family member, or someone else present for this appointment, please tell the doctor beforehand.

The initial appointment takes approximately 30 minutes with the nurse, and then 15 minutes with your regular GP to finalise everything.

GP Chronic Condition Management Plans can be prepared every 12 months. Once in place, the plan could be reviewed every 3-6 months, unless your circumstances change significantly, which would then require an earlier review.

In Australia, individuals aged 75 years and over are eligible for a comprehensive annual health check-up known as the 75+ Health Assessment. This assessment is designed to help older Australians maintain independence, detect health concerns early, and plan appropriate ongoing care.

The 75+ Health Assessment is a Medicare-funded health check for older Australians. The assessment is developed over 2 appointments; the initial 60 minute appointment with the practice nurse, and then a week later a 30 minute appointment with your ususal GP. The assessment covers your medical, physical, psychological, and social wellbeing. The goal is to identify health issues early, support independence, and reduce hospital admissions by promoting proactive healthcare.

During your appointment, your GP and nurse will carry out a comprehensive review, which may include:

Medical history review (including chronic diseases and medications)
Medication management, especially to reduce the risks of polypharmacy
Functional assessment – mobility, balance, falls risk, continence, hearing and vision
Cognitive screening – to check for early signs of memory loss or dementia
Mental health review – including mood and social engagement
Social supports and safety – including living arrangements and care needs
Health promotion advice – including nutrition, exercise, and immunisations
Advance care planning discussions, if appropriate

This detailed assessment allows your GP to create or update a personalised care plan, which may include referrals to allied health providers or community services.

75+ Health Assessments can be done every 12 months.