Chronic Disease Management

Chronic disease care and care plans

We offer individualised care plans for all chronic diseases. Chronic Disease Care plans (GP Management Plans) are a feature of quality general practice, where your doctor prepares a careful review of your health needs, and together you set goals and action plans to optimise your health and quality of life.  Your GP Management Plan can assist you in accessing medicare benefits to reduce the cost of allied health visits (Team Care Arrangements).

How to be involved

Your doctor can arrange specialised team care arrangements, and liaise with your other health providers, where appropriate.

Medication reviews with your pharmacist may be recommended. You will be invited to participate in regular care plan reviews.

There are special programs for patients with asthma and diabetes.

Routine health care assessments are arranged for particular age groups:

  • 4 years

  • 45-49 years

  • Over 75 years of age

Special medicare rebates are available for these initiatives.

Asthma

  • Our goal is to help you in managing your asthma in order to achieve your best possible lung function and to keep symptoms and exacerbations to a minimum.

  • Specialised lung function tests (spirometry) are performed on site to assist with diagnosis and monitoring of asthma.

Diabetes

  • To prevent complications with diabetes, it is important to monitor and control cholesterol, blood pressure and kidney health as well as glucose levels and body weight.

  • We work together with our nurse practitioner, dieticians, specialists and exercise physiologists to help you manage your diabetes.

Aged health assessments

  • If you are 75 years of age or over, one of our nurses will contact you to arrange an annual health assessment.
  • Your nurse will discuss issues affecting your safety and independence as well as checking your medications.

Our Team

Dr. Marcus Middleton
Dr Middleton graduated from the University of WA in 1980. After internship and residency at Fremantle Hospital, spent a ...
Dr. Marcus Middleton
Dr. Liz Davidson
Liz began her General Practice training in 2012, working initially in Fremantle, followed by a year in Midland and a yea...
Dr. Liz Davidson
Dr. Mark Smith
Mark is an experienced English trained GP who moved from the south coast of the UK to Fremantle five years ago. He has i...
Dr. Mark Smith
Dr. Michelle Musca
About Michelle was born and raised in Perth, and completed her medical degree at the University of Western Australia in ...
Dr. Michelle Musca
Dr. Linda Muntz
Dr Muntz completed her medical degree at the University of Western Australia in 1991 and then worked at Fremantle Hospit...
Dr. Linda Muntz
Dr. Jessica Millman
Jess studied medicine at the University of Western Australia, graduating in 2009.  Completing her GP training in the Ki...
Dr. Jessica Millman
Dr. Elizabeth Jaskolski
She is proud to call herself a Freo local after moving to the port city in 2013.  “My husband and I love the beach li...
Dr. Elizabeth Jaskolski
Dr. Nathalie Departe
Joined Ellen Health in July 2014. Previously she worked as a GP in Geraldton, Fremantle GP after hours service and Cool...
Dr. Nathalie Departe
Jille Burns
In 2011 Ellen Health were delighted to be one of the first practices in WA to welcome an independent nurse practitioner ...
Jille Burns