Chronic Disease Management and Preventative Health Measures
Care Plans
A chronic condition is one that lasts for at least 6 months; e.g. asthma, heart disease, diabetes, arthritis, cancer or endometriosis. These conditions can be complex and need ongoing, special care and attention, and it’s important to get the help you need to treat and manage them.
A Chronic Disease Management (CDM) Plan (also known as a GP Management Plan) is suitable for patients who require a structured approach to their care, including those who would benefit from a multidisciplinary team.
A long appointment (30 minutes) with the practice nurse is required to complete a CDM Plan followed by a 20 mins appointment with your regular GP. During this consultation your GP will get a detailed history of your health condition and lifestyle and insight into what could potentially impact your quality of life.
Your GP in conjunction with the practice nurse will then set specific actions and targets, which will help you achieve your health goals. A CDM Plan will also include an agreed timeline of when will next see your GP to review and monitor your progress.
If your GP determines that you could benefit from being treated by a specialist or an allied health professional, they will complete what is known as a Team Care Arrangement (TCA).
If you have two or more health provides involved in your care (in addition to your GP) you are eligible for 5 visits to an allied health provider (e.g. physiotherapist), with a Medicare rebate per calendar year.
These providers will provide a report to your GP after the completion of the first, and last service detailing any investigations or tests they completed, treatments provided and any future management.
Health Assessments
The following categories of health assessments may be undertaken by your medical practitioner with your consent:
- a health assessment for people aged 45-49 years who are at risk of developing chronic disease (once off only)
- a type 2 diabetes risk evaluation for people aged 40-49 years with a high risk of developing type 2 diabetes as determined by the Australian Type 2 Diabetes Risk Assessment Tool
- a health assessment for people aged 75 years and older (offered annually)
- a comprehensive medical assessment for permanent residents of residential aged care facilities
- a health assessment for people with an intellectual disability (offered annually)
- a health assessment for refugees and other humanitarian entrants. (once off)
Health Assessment for Aboriginal and Torres Strait Islander People
This assessment is available for the following for the following age groups:
- Aboriginal and Torres Strait Islander children who are less than 15 years old
- Aboriginal and Torres Strait Islander adults who are aged 15 years and over but under the age of 55 years
- Aboriginal and Torres Strait Islander older people who are aged 55 years and over
Please note that Care plans and Health assessments are BULK-BILLED and do not incur an out of pocket cost.
A Domiciliary Medication Management Review (DMMR)
A DMMR is a personalized assessment conducted by an accredited pharmacist in the comfort of your home. The review focuses on medication therapy, with the goal of maximizing the benefits of the medications and minimizing potential side effects.
The DMMR process often includes general health and medication education to improve patients quality of life. To initiate a DMMR, a referral from your GP is required. Once referred, an accredited pharmacist will conduct the review, and a detailed report will be sent to your GP. The findings will then be discussed with you during a follow-up appointment.
To arrange a Home Medicines Review for yourself or a loved one, please speak to your regular doctor. They will guide you through the process of coordinating a visit from an accredited pharmacist in collaboration with your treating doctor.
Please note that DMMRs are BULK-BILLED and do not incur an out of pocket cost.