Chronic Disease Management

The latest National Health Survey reports that 11.4 million Australians now have chronic disease.

Chronic diseases are long term conditions that may gradually progress over time, may have persistent effects, and require ongoing medical attention. Chronic conditions, by nature of the length of time they affect people, are often complex to manage. This management often requires a team of health professionals and Allied Health providers. Common chronic diseases include, for example:

  • Asthma

  • Arthritis

  • Diabetes

  • Epilepsy

  • Dementia

  • Osteoporosis

  • Parkinson's disease

  • Heart disease

  • Kidney disease

  • Inflammatory bowel disease

  • Cancer

What is Chronic Disease Management?

Chronic Disease Management is ongoing care and support provided by multiple health professionals which is enabled via Medicare rebates to patients for this purpose specifically. This may involve regular visits to, and support from, your GP, other care providers or specialists, and community-based programs and services.

The Chronic disease program provides medical care, education, skills and resources that patients need to better manage their health condition on a day to day basis. Improved health outcomes are expected to follow.

If you have a chronic medical condition, you may be eligible for services under a General Practitioner Management Plan (GPMP) and/or a Team Care Arrangement (TCA). GPMPs and TCAs assist practitioners in coordinating the care of people with chronic conditions.

Aside from helping to reduce the need for ad hoc consultations, Care plans also help in keeping comprehensive, accurate and up-to-date records of a patient's condition and treatment.

The Medicare rebates allocated and accessed for patients via Chronic disease management allows GP’s, Practices and Allied Health professionals to provide care for these chronic diseases that are often complex and time consuming.

GP Management Plan

A GPMP is a plan of management that your GP develops and writes during the course of your consultation, with your input. Your GP may also seek assistance from our qualified Practice Nurses in writing these plans. It is a set of information about your needs in managing your chronic health condition. The plan includes:

  • identification of your health priorities

  • the recommended actions for you to take in order to manage your condition effectively

  • other health care and community services that you may need (if any)

  • the goals that you would want the GPMP to help you with

Team Care Arrangements

If your GP sees that you need the care of other health care providers or allied health professionals such as physiotherapist, dietitian, podiatrist, or audiologist, he/she will facilitate a Team Care Arrangement for you with your consent.

Under these programs, you will be eligible to visit these health professionals up to 5 visits a year, in total, and a Medicare rebate to you will be triggered. Depending on the fees of the provider, a gap may be payable for services or the rebate may cover the entire fee.

Do You Qualify?

If you have a medical condition that has been persisting, or is expected to persist, for at least six months, or you have a terminal illness, you may be eligible for Chronic disease management programs.

You can benefit from both the GPMP and TCA Plan if your condition requires ongoing treatment from a multidisciplinary team.

Your eligibility can be determined by your GP based on the guidelines and requirements set by Medicare. If you qualify for GPMP/TCA, your GP will inform you of your eligibility and together you will agree on your plans.

Medicare Rebates

Your GP can determine whether a chronic condition would benefit from Allied health services. The need for these services must be identified in your care plan and this is where a TCA is completed. Some conditions may be managed by your GP alone and Allied health input may not be required. The patient rebates attached to Chronic disease management allow your Medical Practice and Allied Health providers to continue to provide timely and cost-effective care to you.


Once your GP Management Plan (GPMP) and/or Team Care Arrangements (TCAs) are in place, they will then need to be reviewed on a regular basis, normally three to six monthly.

In time, your conditions and circumstances may change, so it is important that your GPMP and/or TCA plans be reviewed so the plan can be changed. Goals are reviewed as being met, needing to be changed or new goals may be identified.

While Chronic Disease Management may help you adjust to living with and managing your chronic condition, taking a preventive approach before you become unwell is still the best path to take.

Lifestyle factors, good nutrition, enough exercise, and regular checkups can help you avoid many diseases.

Ready for an appointment? You can book online or phone Peregian Family Medical Centre on 07 5471 2100.