What Is a Chronic Disease Management Plan?
A Chronic Disease Management Plan is a structured, Medicare-supported plan your GP prepares when you are living with a long-term health condition, setting out your health goals and coordinating the different health professionals involved in your care. It brings together two Medicare items: a GP Management Plan and, where other health professionals are involved, Team Care Arrangements.
At Shire Family Medical in Sutherland, chronic disease management plans are prepared for patients managing ongoing conditions such as diabetes, high blood pressure, high cholesterol, asthma and thyroid disease — conditions that benefit from a planned, coordinated approach rather than being addressed appointment by appointment.
Shire Family Medical, a GP medical centre at 154 Flora Street, Sutherland, has supported patients with ongoing conditions for more than 11 years. A Chronic Disease Management Plan is one of the practical tools your GP may use to structure that ongoing care, particularly where allied health input — such as a podiatrist, dietitian or exercise physiologist — is likely to help.
GP Management Plan vs Team Care Arrangements: What’s the Difference?
A GP Management Plan (GPMP) sets out your health needs, agreed goals and the actions your GP will take to manage your condition, while Team Care Arrangements (TCA) formally bring at least two other health or care providers into that plan. The two items are usually organised together, but they serve slightly different purposes.
The GPMP is the foundation — it documents your diagnosis, treatment goals, and the GP’s role in monitoring and reviewing your condition over time. Team Care Arrangements build on this when your GP identifies that your care would benefit from input beyond general practice: a podiatrist for diabetes-related foot care, a dietitian for cholesterol or weight management, a physiotherapist for chronic pain, or a psychologist where a chronic physical condition is affecting mental health.
Not every patient needs both. Some patients are well managed with a GPMP alone, reviewed regularly by their GP. Others, particularly those with more complex or multiple conditions, benefit from the coordinated, multidisciplinary approach that Team Care Arrangements provide.
Which Conditions Are Managed Under a Chronic Disease Management Plan?
A Chronic Disease Management Plan may be appropriate for any medical condition that has been present, or is likely to be present, for six months or longer. There is no fixed list of eligible conditions — whether a plan is appropriate is a clinical judgement made by your GP, based on your individual circumstances and care needs.
Conditions commonly managed this way include:
- Type 2 diabetes and pre-diabetes
- Hypertension (high blood pressure)
- High cholesterol and other lipid disorders
- Asthma and chronic obstructive pulmonary disease (COPD)
- Thyroid conditions
- Chronic pain and musculoskeletal conditions, including arthritis
- Cardiovascular disease
- Chronic kidney disease
Many patients living with one of these conditions are also managing others at the same time — high blood pressure and high cholesterol are frequently reviewed together, for example, since both contribute to the same cardiovascular risk. Type 2 diabetes, thyroid disorders and weight-related conditions also commonly overlap. A Chronic Disease Management Plan allows your GP to look at these conditions as a connected picture — one set of goals, one shared set of test results, one coordinated review — rather than managing each condition as a separate, unrelated issue.
What Does Setting Up a Plan Actually Involve?
Setting up a Chronic Disease Management Plan involves a dedicated consultation with your GP to review your condition, agree on health goals, and identify which allied health services — if any — should be included in your Team Care Arrangements. This is a longer appointment than a standard consultation, since it covers more ground than a single issue.
During this appointment, your GP will typically:
- Review your diagnosis, history and current management
- Discuss what you would like to achieve — for example, better symptom control, improved test results, or reduced reliance on medication
- Identify allied health professionals who may support your goals
- Prepare referral letters for those services, where relevant
- Give you a written copy of the plan to keep
This appointment is often a natural extension of a broader health review. If you already have a GP health check-up booked, or one is coming up, it can be a good opportunity to raise whether a Chronic Disease Management Plan would suit your situation — your GP can assess this as part of the same visit rather than requiring a separate appointment in every case.
It’s worth bringing a few things to this appointment: a list of current medications and doses, any recent test results or specialist letters you haven’t yet shared with your GP, and a general sense of what you’d like to see improve — whether that’s better symptom control, more stable test results, or simply feeling more confident managing your condition day to day. The more context your GP has, the more specific your plan can be.
What You Can Do Between Appointments
A Chronic Disease Management Plan works best when it’s supported by consistent habits between GP visits, not just the appointments themselves. Most of the day-to-day work of managing a chronic condition happens at home — taking medication as prescribed, attending scheduled allied health sessions, and monitoring symptoms or readings your GP has asked you to track.
For conditions like diabetes or hypertension, this might mean keeping a simple log of blood glucose or blood pressure readings to bring to your next appointment. For asthma, it may mean noting how often you’re using reliever medication. These small, consistent records often tell your GP more about how well a condition is being managed than a single snapshot taken during a consultation.
If something changes between scheduled reviews — new symptoms, side effects from medication, or difficulty attending allied health appointments — it’s worth contacting the practice rather than waiting for the next review date. Plans are meant to flex around your circumstances, not the other way around.
Medicare Rebates for Allied Health Under the Plan
Medicare provides rebates for a set number of allied health visits each calendar year for patients with an active Team Care Arrangement, covering services such as dietetics, podiatry, physiotherapy, exercise physiology and psychology. The exact number of subsidised visits and current rebate amounts are set by Medicare and reviewed periodically, so it’s worth confirming the current figures directly — your GP can advise, or you can check the latest details on the Services Australia website.
These rebates apply specifically to eligible allied health services accessed under a valid referral from your GP as part of the plan — they are separate from the rebate or fee that applies to your GP consultations themselves. Fee information for GP appointments at Shire Family Medical is available on our fees and billing page.
How Often Is a Chronic Disease Management Plan Reviewed?
A Chronic Disease Management Plan is typically reviewed by your GP around every six months, though this can happen sooner if your condition changes or your treatment needs adjusting. Review appointments give your GP the chance to check progress against the goals set in your original plan, update referrals if needed, and confirm the plan still reflects your current health.
Blood tests often form part of this review — for example, HbA1c for diabetes, or a lipid panel for cholesterol management. Shire Family Medical offers onsite pathology collection after a GP referral, which can make it more straightforward to complete review testing without a separate trip elsewhere. Our article on what happens after your blood test results explains how these results are typically followed up.
A plan does not need to wait for its six-month review if something changes sooner. If your symptoms worsen, a new condition emerges, or your circumstances change significantly, it’s worth booking a GP appointment to discuss whether your plan needs updating ahead of schedule.
Chronic Disease Management at Shire Family Medical
Ongoing conditions are usually managed best when the same GP knows your history, your goals and how your treatment has progressed over time — rather than starting from scratch at each visit. With a team of doctors who see patients across the Sutherland Shire for chronic conditions including diabetes, hypertension, high cholesterol, asthma and thyroid disease, continuity of care is a practical, everyday part of how appointments are structured.
If fatigue, unexplained symptoms or a new diagnosis are part of what brought you to think about a Chronic Disease Management Plan, our article on persistent fatigue and when it’s worth seeing your GP may also be useful background reading.
If you’re living with an ongoing condition and haven’t yet discussed a Chronic Disease Management Plan with your GP, it’s a reasonable thing to raise at your next appointment — or to book a dedicated visit to talk it through. Book an appointment with Shire Family Medical →
Frequently Asked Questions
What is a Chronic Disease Management Plan?
A Chronic Disease Management Plan is a Medicare-supported plan a GP prepares for a patient with a long-term health condition, combining a GP Management Plan with Team Care Arrangements where other health professionals are involved. It sets out health goals and coordinates the care needed to work towards them.
What’s the difference between a GP Management Plan and Team Care Arrangements?
A GP Management Plan documents a patient’s condition, goals and the GP’s role in ongoing care. Team Care Arrangements formally involve at least two other health professionals, such as a dietitian or physiotherapist, in that same plan. The two are usually set up together but serve different functions within a patient’s overall care.
What conditions qualify for a Chronic Disease Management Plan?
Any medical condition that has been present, or is likely to be present, for six months or longer may qualify for a Chronic Disease Management Plan, including diabetes, hypertension, high cholesterol, asthma, thyroid conditions and chronic pain. There is no fixed list — eligibility is a clinical judgement made by the patient’s GP.
How many allied health visits does Medicare cover under a Chronic Disease Management Plan?
Medicare provides rebates for a set number of allied health visits each calendar year under an active Team Care Arrangement. The exact number of visits and rebate amounts are set by Medicare and can change, so patients should confirm current details with their GP or check the Services Australia website directly.
How often is a Chronic Disease Management Plan reviewed?
A Chronic Disease Management Plan is typically reviewed by a GP around every six months, though a review can happen sooner if a patient’s condition changes or their treatment needs adjusting. Reviews often include relevant blood tests and an update to referrals as needed.
Do I need a referral to see allied health providers under the plan?
Yes. Allied health services accessed under Team Care Arrangements require a referral from the patient’s GP as part of the Chronic Disease Management Plan. This referral confirms the service is being provided as part of a coordinated care plan, which is what allows the Medicare rebate to apply.
Can a Chronic Disease Management Plan be set up during a regular check-up?
In many cases, yes — a routine GP health check-up can be a suitable opportunity to discuss whether a Chronic Disease Management Plan is appropriate. Depending on how much needs to be covered, the GP may complete the plan during that visit or recommend booking a dedicated longer appointment.
Is a Chronic Disease Management Plan only for older patients?
No. A Chronic Disease Management Plan is based on whether a patient has a long-term condition expected to last six months or longer, not on age. Younger adults managing conditions such as asthma, type 2 diabetes or thyroid disorders can be just as suitable for a plan as older patients.
This article provides general health information only. It is not a substitute for personalised medical advice and does not create a doctor-patient relationship. Any treatment, test, procedure or vaccination mentioned is for illustrative purposes only — suitability depends on individual circumstances and assessment by a qualified health professional. Medical information can change; always speak with your GP about your specific symptoms, health history and care options. In an emergency, call 000.
