Chronic Disease Management

At JJFP we are fortunate to have a dedicated team of experienced Nurses and Doctors who work together to enhance the care of our patients with Chronic Diseases.  These include:

  • Diabetes Mellitus
  • Asthma
  • Heart disease
  • Psychiatric Conditions
  • Obesity
  • Palliative Care
  • Emphysema / Bronchitis
  • and many other conditions.

Many of our patients with Chronic Diseases will be eligible for a Care Plan.

Care Plans

There are two types of plans that can be prepared by a General Practitioner (GP) for Chronic Disease Management (CDM):

◦ GP Management Plans (GPMP); and

◦ Team Care Arrangements (TCAs)
If you have a chronic (or terminal) medical condition, your GP may suggest a GPMP.

If you also have complex care needs and require treatment from two or more other health care providers, your GP may suggest TCAs as well.

Your GP or practice staff must obtain your agreement before providing these plans.

At JJFP we accept the Medicare benefit as full payment for the service, there will be no out-of-pocket cost.
If you have both a GPMP and TCAs prepared, you may be eligible for Medicare rebates for certain allied health services. It is up to your GP to determine whether you are eligible for these allied health services which must be directly related to the management of your chronic condition.

• The practice nurse can provide support and monitoring between visits to your GP.

• Your GP will offer you a copy of your plan.

• You and your GP should regularly review your plan/s.

Chronic medical conditions

A chronic medical condition is one that has been (or is likely to be) present for six months or longer, for example, asthma, cancer, heart disease, diabetes, arthritis and stroke. There is no list of eligible conditions. However, these items are designed for patients who require a structured approach and to enable GPs to plan and coordinate the care of patients with complex conditions requiring ongoing care from a multidisciplinary care team. Your GP will determine whether a plan is appropriate for you.

GP Management Plan

A GP Management Plan (GPMP) can help people with chronic medical conditions by providing an organised approach to care. A GPMP is a plan of action you have agreed with your GP.

This plan:

• identifies your health and care needs;

• sets out the services to be provided by your GP; and

• lists the actions you can take to help manage your condition.

Team Care Arrangements

If you have a chronic medical condition and complex care needs requiring multidisciplinary care, your GP may also develop Team Care Arrangements (TCAs). These will help coordinate more effectively the care you need from your GP and other health or care providers.
TCAs require your GP to collaborate with at least two other health or care providers who will give ongoing treatment or services to you. Let your GP or nurse know if there are aspects of your care that you do not want discussed with other health care providers.

Review of GPMPs and TCAs

Once a plan is in place, it should be regularly reviewed by your GP. This is an important part of the planning cycle, where you and your GP check that your goals are being met and agree on any changes that might be needed.

Referrals for Allied Health Services

If you have both a GPMP and TCAs prepared for you by your GP, you may be eligible for Medicare rebates for specific individual allied health services that your GP has identified as part of your care. The need for these services must be directly related to your chronic (or terminal) medical condition. If you have type 2 diabetes and your GP has prepared a GPMP, you can also be referred for certain allied health services provided in a group setting.

More Information

The explanatory notes and item descriptors for these items are available online: Department of Human Services.
For inquiries about eligibility, claiming, fees and rebates, call the Department of Human Services (Medicare): 132 011