Chronic Disease Management

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Chronic Diseases

The Department of Health defines a Chronic Disease as


The Department of Health defines a Chronic Disease as an illness that is prolonged in duration, lasts longer than 6 months, is often not spontaneous to resolve, and is rarely completely cured. Chronic diseases are complex and varied in terms of their nature, how they are caused and their impact on the community. While some chronic diseases make large contributions to premature death, others contribute more to disability. Features common to most chronic diseases include; 

  • complex causality, with multiple factors leading to their onset
  • a long development period, for which may there may be no symptoms
  • a prolonged course of illness, perhaps leading to other health complications
  • associated with functional impairment or disability

Chronic disease management is complex and varied and requires input from your GP or diabetes doctor.

There are two kinds of chronic disease management plans for patients:

  • A GP Management Plan
  • A Team Care Arrangement

A GP Management Plan

GP Management Plans are designed for all patients with a chronic disease and help them with chronic disease management.

A chronic disease management plan involves a consultation with your GP, who will work in conjunction with you to formulate a written care plan tailored to each individual, to specifically help with chronic disease management. Your medical, physical, psychological and social needs are all considered during the development of a chronic disease management plan drafted by your GP.

Together you will decide:

  • What are your health care problems and needs?
  • What results you would like to achieve through the Plan?
  • What, if any, other health care and community services do you need?

Once the chronic disease management plan is developed, we will then make an appointment with your diabetes doctor to discuss the findings and recommendations. You will also be given a copy of the chronic disease management plan. If you would like a carer, family member or someone else present for these appointments, please tell the nurse or diabetes doctor beforehand.

The initial appointment takes approximately 45 minutes for our practice nurse. Your GP will then take a further 15 minutes to develop and authorise the plan.

GP Chronic Disease Management Plans can be prepared every two years. Once in place, the plan should be reviewed every 6 months, unless your circumstances change significantly, which would then warrant an earlier review. Main Street Medical will regularly remind you when you are due for a review or new plan.

Searching “diabetes doctors near me”? Reach out to us!

A Team Care Arrangement

A Team Care Arrangement is a plan developed in consultation with the GP and diabetes doctors near me, which requires input from Allied Health professionals including; a Physiotherapist, Occupational Therapist and Diabetes Educator.

A Team Care Arrangement may be done in addition to a GP management plan. In much the same way as a GP Management Plan, a Team Care Arrangement works to improve your health by identifying and targeting long-term health issues.

A team care arrangement is specific for patients with complex care needs and enables eligible patients to access Medicare-subsidised Allied Health visits. This is proven beneficial to improving health and well-being.

Looking for “diabetes doctors near me”? Main Street Medical is the place for you!

How much do chronic disease management plans cost?

Medicare covers the cost of each plan. There is NO out-of-pocket cost.

Looking for “Doctors near me”? Phone (03) 9739 3837 to book an appointment with your doctor to discuss your need for a GP management plan and Team Care Arrangement.

A chronic medical condition, if poorly managed, can be debilitating. Through coordinated management, our general practitioners and nurses work together to maintain, observe and improve quality of life. This is a bulk-billed service and is highly encouraged for sustaining optimal health. If you’re looking for a medical clinic near me, reach out to us at the earliest.