Chronic Disease Management Plans

Chronic disease management plans form part of our commitment to the health of our local community. Our doctors can provide management plans for patients who suffer with a chronic medical condition.

Chronic Medical Conditions

A chronic medical condition is one that has been present for at least six months or longer, such as:

  • Asthma
  • Cancer
  • Cardiovascular disease
  • Diabetes
  • Musculoskeletal conditions
  • Stroke

Chronic Disease Management Plans

Chronic disease management plans are designed by general practitioners for patients who have complex conditions that require ongoing care, and a structured approach.

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.

Regular Reviews

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.

We offer care plans to all eligible patients who suffer from a chronic illness with little or no cost to the patient.

Patients are asked to book an appointment with their GP to determine if they are eligible. Our practice nurse will provide support and monitoring between visits to your GP.

For more information about chronic disease management, please contact us.