Chronic Disease Management in Hornsby

Florence Street Family Practice provides comprehensive chronic disease management in Hornsby, delivered by fully qualified General Practitioners experienced in primary care and family medicine. Our services include structured care plans, scheduled reviews, and coordination with allied health professionals to support ongoing treatment. We focus on patient involvement and self-management strategies to improve health outcomes. From children to older adults, we offer compassionate, consistent care tailored to individual needs. With a strong commitment to continuity and quality of care, our team works closely with you to manage chronic conditions effectively and enhance your overall well-being.

Call (02) 94762255 for Chronic Disease Management at our medical centre in Hornsby from expert GPs providing medical treatments to chronic disease management for each individual.

What is a Chronic Condition?

Chronic conditions are long-term health issues that last, or are expected to last, six months or more. These may include asthma, diabetes, heart disease, cancer, arthritis, dementia, and musculoskeletal disorders. Such conditions often require ongoing medical support and a coordinated approach to care. Your GP may recommend a structured management plan if your condition is complex and needs input from multiple health professionals. There is no set list of eligible conditions—your doctor will assess your needs to determine if a care plan is appropriate for you.

What is Chronic Disease Management?

Chronic disease management is a structured approach to helping patients manage long-term health conditions through medical treatment, lifestyle modifications, and self-care support. It focuses on slowing disease progression, reducing complications, and improving quality of life. At Florence St Family Practice, we work with you to create personalised care plans that promote early intervention, encourage self-management, and connect you with allied health services as needed for ongoing, coordinated care.

Chronic Conditions We Provide Care For

We provide primary care services for adults, ensuring your overall well-being and addressing any health concerns.

Heart Disease
Cancer
Diabetes
Arthritis
Asthma
Chronic Obstructive Pulmonary Disease (COPD)

Mental Health Conditions
Dementia
Chronic Kidney Disease
Osteoporosis
Endometriosis
Multiple Sclerosis
Epilepsy

Migraine
HIV/AIDS
Parkinson’s Disease
Sickle Cell Disease
Ulcerative Colitis
Crohn’s Disease
Cystic Fibrosis
Obesity

What Our CDM Care Plan Covers?

A Medicare care plan helps manage chronic conditions by outlining goals, treatments, and referrals. Your GP will assess your needs, create a plan, and coordinate with allied health providers. Regular reviews ensure your care stays on track.

GP Management Plans (GPMP)

A GP Management Plan (GPMP) is a structured care plan developed between you and your GP to manage a chronic medical condition. It outlines clear goals and steps to support your health and improve your quality of life.

The GPMP includes:

Assessing your condition with your overall health and daily functioning
Defining your GP’s clinical goals for managing the condition
Considering your personal needs and health goals
Planning specific treatments and actions to meet those goals
Setting review dates to monitor progress and make adjustments

The GPMP helps ensure continuity of care and provides a clear framework for managing chronic illness effectively.

Referrals for Allied Health Services

If your GP has developed a Team Care Arrangement (TCA) for you, you may be eligible for Medicare rebates on certain allied health services, such as physiotherapy, podiatry, dietetics, or psychology. These services must be directly related to managing your chronic or terminal condition and included in your care plan. Your GP will determine the type of services needed and refer you accordingly. TCAs ensure that your care is coordinated between your GP and other healthcare providers, supporting better outcomes through a team-based approach.

Team Care Arrangements (TCAs)

Patients with chronic conditions and complex care needs may benefit from Team Care Arrangements (TCAs). These are structured care plans that allow your GP to coordinate ongoing treatment with at least two other health or care providers.

TCAs involve:

Collaboration between your GP and other providers, such as allied health professionals or specialists
Documenting each provider’s goals and planned treatments
Coordinating services to ensure all aspects of care are aligned

You can inform your GP or nurse if there are elements of your care you prefer to keep confidential from other providers. The practice nurse may also assist with follow-up and support between GP visits. Your care plan should be reviewed regularly to track progress and adjust as needed.

Why Choose Florence St. Family Practice for Chronic Disease Management?

Experienced GPs

Our fully qualified GPs at Florence St Family Practice bring years of experience in diagnosing and managing chronic conditions such as diabetes, heart disease, asthma, arthritis, and other long-term illnesses. Their clinical expertise ensures accurate assessments, timely interventions, and coordinated care tailored to each patient’s needs.

Personalised Care Plans

Each care plan is developed to match your specific health condition, daily routine, and long-term goals. These plans provide clear steps for managing your chronic illness and are regularly reviewed to ensure they remain relevant and effective.

Collaborative Approach

Our GPs coordinate with nurses, allied health providers, and specialists to deliver integrated care tailored to your condition. This team-based approach ensures clear communication between providers, avoids duplication, and supports consistent treatment across all aspects of your health.

Continuity of Care

You’ll be cared for by the same trusted GPs at each visit, supporting consistent monitoring and a deeper understanding of your medical history. This long-term approach helps us deliver better, more personalised treatment over time.

Focus on Prevention and Self-Management

We provide clear guidance, resources, and education to help you understand your condition and take an active role in managing it. The goal is to reduce complications, prevent hospital visits, and support long-term health through realistic lifestyle changes and regular follow-ups.

Convenient Hornsby Location

Conveniently located at Suite 6, Ground Floor, 32 Florence Street, Hornsby, next to Westfield Shopping Centre, our practice offers easy access for all. Heading down Florence St from the railway station, past the fountain and Westpac building, cross the small laneway to find our building. The entrance is inside the main doors of the building and turn left at the lifts and follow the corridor to the reception on the right. Our facility is fully accessible for individuals with disabilities, and we offer ample parking space right in Westfield Shopping Centre.

Visit Florence St Family Practice at Suite 6, Ground Floor, 32 Florence Street, Hornsby for Chronic Disease Management by expert General Practitioners providing the utmost care and helping patients manage their disease.

Our medical centre offers flexible appointment times to suit busy schedules, ensuring patients can receive timely support and ongoing care from experienced GPs.