Ongoing Chronic Disease Care Planning
Our chronic disease management service provides ongoing, coordinated care for patients living with long-term health conditions. Our GPs work closely with you to monitor your health, manage medications, coordinate allied health services, and develop personalised care plans that support better long-term outcomes. Whether you're managing diabetes, heart disease, asthma, COPD, kidney disease, arthritis, osteoporosis, or multiple chronic conditions, we're here to help you stay healthy and maintain your quality of life.
Living with a chronic condition requires more than repeat prescriptions. Our GPs develop structured, personalised GP Management Plans that set out your health goals, treatment strategy, and the team of professionals involved in your care. Under Team Care Arrangements, we coordinate referrals to dietitians, physiotherapists, psychologists, and other allied health with Medicare rebates — making it easier to access the full spectrum of care your condition requires. We review and update your plan regularly, track your progress on blood pressure, glucose, cholesterol, and other key markers, and adjust treatment as your needs change.
GP Management Plans (GPMP) — structured, documented care goals
Team Care Arrangements (TCA) — up to 5 Medicare-rebated allied health visits
Regular review consultations — medication, lifestyle, and monitoring
On-site blood tests and ECG for routine monitoring
Coordinated referrals to specialists and allied health
Coordinated Care for Long-Term Conditions
Managing a chronic condition is a long game. Our GPs work with you — and a coordinated team — to build a plan that keeps you healthy, informed, and in control.
Regular Review
We schedule review appointments to track your progress, update your plan, manage medications, and ensure your care stays on track as your condition evolves.
Allied Health Coordination
Under Team Care Arrangements, your GP refers you to the right allied health professionals — with Medicare rebates attached — so the full team works together toward your goals.
Care Plan Development
Your GP completes a comprehensive assessment and documents your GP Management Plan — covering your diagnosis, goals, medications, and the team involved in your care.
What to Expect During Your Visit
