Chronic Disease Care

The definition of Chronic Disease as per the Department of Health Australia is…….

Illness that is prolonged in duration, does not often resolve spontaneously, and is rarely cured completely. Chronic diseases are complex and varied in terms of their nature, how they are caused and the extent of their impact on the community. While some chronic diseases make large contributions to premature death, others contribute more to disability. Features common to most chronic diseases include:

  • complex causality, with multiple factors leading to their onset
  • a long development period, for which may there may be no symptoms
  • a prolonged course of illness, perhaps leading to other health complications
  • associated functional impairment or disability.

There are two kinds of management plans for patients with a chronic disease:

  • A GP Management Plan
  • A Team Care Arrangement

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

A GP Management Plan involves you, your GP and another health care professional, 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.

Together you will decide:

  • What your health care problems and needs are
  • What results you would like to achieve through the Plan
  • What, if any, other health care and community services you need

Once the Management Plan is developed, we 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 our practice nurse. Your GP will then take a further 15 minutes to develop and authorise 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. Main Street Medical and Skin Centre will regularly remind you when you are due for a review or new plan.

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 to some subsidised visits to Allied Health Professionals, that woud 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?

Medicare covers the cost of each plan. There is no out of pocket cost to patients. Contact reception to book a long consult to discuss your options and what we can do for you.