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Chronic Disease Care Plans

A health assessment of an older person is an in-depth assessment of a patient aged 75 years and over. It provides a structured way of identifying health issues and conditions that are potentially preventable or amenable to interventions in order to improve health and/or quality of life.

Chronic Disease Management Plans

People with a chronic medical condition may be able to access Medicare benefits to cover allied health services that help manage their condition.

For any patients who experience chronic illness such as heart disease, arthritis, kidney disease, asthma or any other condition that lasts for more than six months, we offer a supportive nurse-led clinic to ensure your care is optimal. In conjunction with your GP, you will receive a written plan outlining your health goals, activities and other medical or allied health specialists who are involved in your care.

Chronic medical condition

A chronic medical condition is one that has been, or is likely to be, present for at least 6 months or is terminal.


Anyone with a chronic or terminal medical condition can have a GP Management Plan in place.

Chronic Disease Management Plan

If you have a chronic medical condition, your doctor may suggest a GP Management Plan.

This plan of action agreed between you and your GP:

  • identifies your health care needs
  • sets out the services to be provided by your GP and
  • lists the actions that you need to take

If you need treatment from 2 or more health professionals, your doctor may also put a Team Care Arrangement plan in place for you. This lets your doctor work with, and refer you to, at least 2 other health professionals who will provide treatment or services to you.

Access to Allied Health

You may be eligible for Medicare benefits for specific allied health services if your doctor prepares both types of plans for you.

What is invovled?

Our nurses will arrange an appointment  to meet with you at our clinic to review your current health issues.  

They will arrange consultations for you, with your regular  GP who will also consult with you to review your chronic health issues. 

The nursing staff will also assist both you and your GP to set up all appointments and tests as required to ensure you have access to healthcare providers, and that your health concerns are well managed at all times.