Chronic Disease Management

An integrated care approach to managing illness which includes screenings, check-ups, monitoring and coordinating treatment, and patient education.

What is a chronic disease?

A chronic disease is a medical condition that has been present for an extended period or is likely to be present for a minimum of six months. These diseases often require ongoing medical attention or may limit daily activities. Some common chronic diseases that affect many individuals include:

  • asthma

  • diabetes

  • cancer

  • osteoporosis

  • arthritis

  • back problems

  • cardiovascular disease

  • chronic obstructive pulmonary disease (COPD)

  • dementia

  • chronic kidney disease

  • endometriosis

Chronic conditions can affect people of all ages but they tend to become more common as we get older.

GP Chronic Condition Management Plan (GPCCMP)

A GPCCMP helps patients with chronic health issues by organising their care with a structured approach. It consists of a GP and practice nurse getting a detailed review of a patient’s lifestyle and insight into what could potentially impact their quality of life. The GP will set goals and targets for the patient’s health.

Sometimes patients with chronic disease require a collaborative approach towards their healthcare. This is where a multidisciplinary approach can be useful to support patients. This may involve your GP working with specialists or allied health professionals who will continue your treatment.

Regular Reviews

Once a plan is set, your GP should review it regularly. This step ensures your goals are being met and any necessary changes are made. We provide care plans at no cost for eligible patients with chronic illnesses. Patients should schedule an appointment with their GP to check eligibility. Our practice nurse will support and monitor you between GP visits.