Chronic Disease Management

Many GP visits occur because a patient has an acute problem

When neither the patient nor doctor can effectively address long-term management of the chronic condition causing the problem.

Evidence shows that chronic disease management (CDM) strategies lead to improved health outcomes for people with chronic conditions. CDM includes planned visits, care coordination, quality links with allied health service, and patient involvement in self-management. A written care plan is a primary tool in this kind of management.

A GP management plan (GPMP) helps record comprehensive, accurate and up-to-date information about a patient’s condition and treatment to help encourage the patient to take responsibility for their care. This is vital in the management of chronic medical conditions.

What is a chronic condition?

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, diabetes mellitus, mental health conditions (including dementia), and musculoskeletal conditions 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.

What is a CDM care plan?

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

GP Management Plans (GPMP)

In general practice the GPMP provides an organised approach to care. It is a plan of action you have agreed with your GP, “a process for setting and achieving goals”.

This involves:

assessment of the patient’s condition/s in relation to overall health and functionality
outlining the practitioner’s goals for the patient
addressing the patient/carer’s needs and goals
planning treatments and actions which will meet the goals, and
planning review steps.

Referrals for allied health services

If you have a 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.

Team Care Arrangements (TCAs)

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.

TCAs require your GP to organise

collaborate with at least two other health or care providers who will give ongoing treatment or services to you.
collaboration between providers to prepare the plan.
recording of each party’s goals and the treatment/care planned to meet those goals.
Let your GP or nurse know if there are aspects of your care that you do not want discussed with other health care providers.
The practice nurse can provide support and monitoring between visits to your GP.
regular You and your GP should regularly review your plan/s.