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Chronic Disease Management

Chronic Disease Management

Care Plans

There are two types of Care Plans:

  • GP Management Plans (GPMP); and

  • Team Care Arrangements (TCA)

Your GP may suggest a GPMP if you have a chronic and complex medical condition.

If you also have complex care needs and require treatment from two or more other health care providers, your GP may suggest a TCA as well.

What is a chronic medical condition?

A chronic medical condition is one that has been (or is likely to be) present for six months or longer. For example:

  • Lung disease, including athsma and COPD

  • Cancer

  • Heart disease, including coronary artery disease, heart failure, and atrial fibrillation

  • Diabetes

  • Arthritis

  • Chronic kidney disease

  • Stroke

  • Osteoporosis

  • Bowel disease, such as Crohn's, Ulcerative Colitis, and Coeliac Disease

  • Neurological disease, such as epilepsy and Multiple Sclerosis

  • and more...

What is a GP Management Plan?

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 upon 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.

What are 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 (TCA). 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 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.

Review of GPMPs and TCAs

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. It's recommended that we review your care plans every 3 to 6 months.

Each of these review appointments will also incur no out of pocket costs.

What does it cost?

All appointments solely for Care Plans and Care Plan Reviews have the out of pocket fees waived at Kirrawee Family Medical Practice.

How to arrange a Care Plan appointment at Kirrawee Family Medical Practice

When booking your Care Plan appointment, our Reception team will book you in with the Practice Nurse first and your GP on the same day.

Care Plan appointments typically take about 30 minutes with the nurse, and a standard appointment with your GP.

Health Assessments

Specific medicare item numbers are available enabling Kirrawee Family Medical Practice to waive the fees for all Health Assessments for the following categories:

  • a once-off 45-49 Year Old Health Check for people aged 45-49 years who are at risk of developing chronic disease

  • 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

  • an annual health assessment for people aged 75 years and older, KFMP usually recommends this is done at the time your drivers licence renewal medical is completed

  • an annual health assessment for people with an intellectual disability

  • a health assessment for refugees and other humanitarian entrants

  • an annual ATSI Health Check for people of Aboriginal or Torres Strait Islander origin

Outside of the above categories, health assessments will be privately-billed.

We require a long appointment (60 minutes) for a full check up.

Please discuss with one of our Reception staff or your General Practitioner about arranging a Health Assessment appointment.

Health assessments are generally made up of the following elements:

  • information collection, including taking a patient history and undertaking or arranging examinations and investigations as required

  • making an overall assessment of the patient

  • recommending appropriate interventions and referrals

  • providing advice and information to the patient

  • keeping a record of the health assessment, and offering the patient a written report about the health assessment, with recommendations about matters covered by the health assessment

  • offering the patient’s or their carer (if any, and if the medical practitioner considers it appropriate and the patient agrees) a copy of the report or extracts of the report relevant to the carer.

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