Chronic Disease Management

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)

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.


  • Our goal is to help you to manage your asthma 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.


  • To prevent the complications of 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 or over, one of our Nurses will contact you to arrange an annual health assessment.

  • Our Nurse will discuss issues affecting your safety and independence as well as checking your medications.