Chronic Disease Management

Book Appointment

Chronic Disease Management Plans

There are two kinds of Chronic Disease Management plans (CDM) for patients with a chronic disease:

A GP Management Plan (GPMP)
A Team Care Arrangement (TCA)
chronic disease management

GP Management Plan (GPMP)

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

A GP Management Plan involves you, your GP, and another health care provider, 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 CDM nurse and doctor you will decide:
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

Once the Management Plan is developed, you will then make an appointment with your doctor to discuss the findings and recommendations.

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

The initial appointment takes approximately 45 minutes with a practice nurse. Your GP will then take a further 15 minutes to develop the plan.

GP Management Plans can be prepared every two years. Once in place, the plan should be reviewed every 6 months, unless your circumstances change significantly, which would then require an earlier review.

Team Care Arrangement (TCA)

A Team Care Arrangement is a plan developed by your GP that involves other health care providers or allied health workers. This may be done in addition to a GP Management Plan.In much the same way as a GP Management Plan, a Team Care Arrangement works to improve your health by identifying and targeting long-term health issues.

A TCA is for a patient with a GPMP and with complex care needs. This is defined as anyone who is under the care of at least 2 other health professionals besides their normal GP. If the patient is eligible for a TCA, they may be eligible for some subsidised visits to Allied Health Professionals, that would be beneficial to their overall health and well being.

Other health care providers can include a physiotherapist, medical specialist, community nurse, home help service, occupational therapist, dietitian, diabetes and asthma educators, pharmacists, etc.

What do these plans cost?

Most doctors choose to have Medicare cover the cost of each plan.