Chronic Disease Management
Ongoing support for managing long-term health conditions, with personalised care, regular monitoring and coordinated treatment to help you stay well.
What is a chronic disease?
A chronic disease is a health condition that lasts, or is expected to last, for six months or longer. These conditions often require ongoing care, monitoring and treatment to help manage symptoms and maintain your quality of life.
How chronic disease management works
Managing a long-term condition is an ongoing process. Your GP and practice nurse can work with you to understand your health, set goals and coordinate the care you need.
Understand your health
Your GP and practice nurse can review your condition, medications, lifestyle and other factors that may affect your health.
Set personalised goals
Together, you can establish practical health goals and a plan that reflects your individual needs and circumstances.
Review and adjust
Your care can be reviewed over time so your treatment, monitoring and referrals can be adjusted as your needs change.
GP Chronic Condition Management Plan
A GP Chronic Condition Management Plan (GPCCMP) helps organise the care you need when you have a chronic or long-term health condition. Your GP can work with you to create a structured plan based on your individual health needs and goals.
Personalised care
Your GP will consider your condition, treatment, lifestyle and health goals when developing your plan.
Coordinated healthcare
Where appropriate, your GP can coordinate care with specialists, allied health professionals and other healthcare providers.
Ongoing monitoring
Your health can be monitored over time, with your plan reviewed when needed to make sure it continues to meet your needs.
Practice nurse support
Our practice nurse can support monitoring and follow-up between GP appointments where appropriate.
Am I eligible for a care plan?
GP Chronic Condition Management Plans are available for eligible patients with chronic or long-term health conditions. Eligibility is assessed by your GP based on your individual circumstances.
If you think a care plan may be suitable for you, speak with your GP at your next appointment. Our team can also help explain the process.
Need support managing a chronic condition?
Speak with your GP about your ongoing health needs and whether a GP Chronic Condition Management Plan may be appropriate for you.