Chronic Disease Management

Many of our patients live with chronic disease. By working together, there is a lot we can do to help you live with the best health outcomes possible.


Chronic disease is any health condition that has been, or is likely to be, present for more than six months. These may include:


• Arthritis
• Asthma
• Cancer
• Cardiac Disease
• Chronic Obstructive Pulmonary Disease (COPD)
• Depression and Anxiety
• Diabetes
• Kidney Disease
• Multiple Sclerosis
• Osteoporosis
• Parkinson’s Disease
• Stroke


Often these conditions have more than just a health impact because they can also have a significant effect on a person’s social and emotional wellbeing. 


Living with a chronic condition can be extremely stressful and can involve some significant life changes, so it is important for anyone with a chronic illness to receive well-managed care and health education.


Chronic disease is a major cause of hospitalisation if not addressed with adequate prevention and management strategies. 


People who are affected are more likely to become frequent users of primary and acute health services.

How To Manage Your Chronic Condition

The best place to start is to build an ongoing partnership with your doctor. In managing your condition together, over time, you will improve your chances of better health outcomes.


Another important part of our work is to ensure that you have sound, factual information to help you understand your particular health issues.


A Medicare GP Management Plan (GPMP) is used to help people manage their chronic disease.


This is a care plan which identifies all your health and welfare needs and the services required to address them. 


Things that you can do for yourself are also identified in the plan. This is known as ‘self management’ – a key factor in managing chronic conditions and improving health outcomes.


We offer a supportive nurse-led clinic which is facilitated by our Chronic Disease Nurses who assist you and your doctor to develop your GPMP.


The Chronic Disease Nurse has dedicated time (usually a 30 minute appointment) to help identify your personal health needs and create the best plan for you. 

This is an organised approach to your care. During this time the nurse will:


  • Identify your health and care needs
  • Set out the services to be provided by your doctor
  • List the actions you can take to help manage your condition
  • Identify treatments and ongoing services

The Chronic Disease Nurse works in collaboration with your doctor and he/she will participate in the consultation. This plan will guide you and your doctor in the management of your condition over time. Any services or referrals you need will be discussed and can take up to two weeks to complete.


Chronic illness often involves the care of other health professionals, such as a dietitian, psychologist, podiatrist or physiotherapist. When this is the case Medicare can provide you with a number of subsidised allied health visits (generally 5 visits in total across a calendar year) when your doctor initiates a team referral plan. 


This is called a Team Care Arrangement (TCA). Your doctor will be able to advise you on this.


If you require further information, please talk to one of our doctors or nurses.

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If you have cold or flu type symptoms we kindly ask that you still wear a mask, or wait outside before your appointment. Many Thanks from the Dernancourt Medical Team