Chronic Care Management

We are a supportive provider of chronic care management.

Living with a chronic medical condition can have an impact on every aspect of a person’s life.

Chronic conditions are long term (present or likely to be present for at least 6
months) conditions which may include:

  • Asthma
  • Cancer
  • Cardiovascular disease
  • Diabetes
  • Musculoskeletal conditions
  • Stroke

Chronic conditions can impact the person’s quality of life, but with the right support and management, people with chronic conditions can also live happy and healthy lives. Our Chronic Care Management Team can equip and support you in making sustainable lifestyle changes for the management of your chronic conditions and optimise your long term health.

Services can be arranged as part of a GP Management Plan (GPMP) and Team Care Arrangement (TCA) initiated by a doctor or by referral. You can also access these services privately.

Additionally people living with Type 2 Diabetes are entitled to access our group sessions which are facilitated by our Diabetes Educator, Dietitian and Exercise Physiologist periodically throughout the year. These group sessions are government funded if you have a current GPMP & TCA.

For further information on how to access these group education sessions, please don’t hesitate to ask your GP

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Our nurse supports you and your GP by assisting the GP in engaging in a comprehensive health screen which compares and can potentially identify any changes in your :

  • Vital signs
  • Risk factors for disease
  • Health status

The health assessment also provides opportunity for your GP to:

  • Identify any community supports you may require
  • Other health professionals that you may need to be referred to.

The aim of the health assessment is to support you to live well in your community.

Your GP may identify that you have a chronic condition (for example, diabetes, arthritis, osteoporosis, heart disease or cancer)

A chronic condition may entitle you to be eligible for a GPMP & TCA which will allow your GP to manage and coordinate the ongoing care you receive from all healthcare providers as well as allow you to access allied health services.

Our nurse may be asked to assist you and your GP in the development of the plans that meet your health goals and needs.

Our nurse is able to assist you and your GP to develop your Advance Care Directive.

An Advance Care Directive allows you to record your values and preferences for your future medical treatment should you lose decision making capacity.