Chronic Disease Management Services | The Village GP Black Rock

Chronic Disease Management Services at The Village Black Rock

Living with a chronic illness can be challenging and isolating. At The Village Black Rock, we specialise in providing comprehensive, individualised care for patients managing long-term conditions. Our goal is to ensure you receive the best possible treatment tailored to your unique needs, helping you maintain a fulfilling quality of life. We proudly serve the local community, including Black Rock, Beaumaris, Sandringham, and Cheltenham.

Understanding Chronic Diseases

Chronic medical conditions are those that last for six months or more and can have a significant impact on your physical, emotional, and mental well-being—often affecting daily life, relationships, and overall quality of life. Common examples include asthma, cardiovascular disease, diabetes, cancer, kidney disease, multiple sclerosis, osteoarthritis, thyroid disorders, and Parkinson’s disease. These conditions can significantly impact your physical, emotional, and mental well-being, affecting daily activities, relationships, and overall quality of life.

Chronic Disease Management Plans

We offer Chronic Disease Management Plans designed to provide a structured approach to care for those managing chronic medical conditions. These plans are tailored to meet your specific needs and provide a clear path for ongoing management and treatment.

GP Management Plans (GPMPs)
Team Care Arrangements (TCAs)

A GP Management Plan (GPMP) is an organised approach to managing chronic or terminal conditions. Your GP will develop this plan in collaboration with you. It:

Identifies your health and care needs
Set out the services your GP will provide
Lists actions you can take to help manage your condition effectively

You and your GP will review this plan regularly to ensure it remains relevant to your needs.

For patients with complex care needs that require multidisciplinary support, your GP may recommend Team Care Arrangements (TCAs). These arrangements help coordinate care between your GP and other health professionals. TCAs involve collaboration with at least two other health providers who will deliver ongoing treatment or services. Your GP will work with these providers to ensure all aspects of your care are well-coordinated, but you are always in control of your treatment. Let your GP or nurse know if there are aspects of your care that you do not wish to be shared with other health providers.

Regular Reviews

Once your GPMP and/or TCAs are in place, regular reviews are essential to track your progress. These reviews help ensure that your care plan is achieving your health goals. We typically conduct reviews every 3–6 months, or sooner if needed, to make any adjustments to your care plan.

Multidisciplinary Support Services

Managing chronic disease often involves a team of healthcare professionals. Our multidisciplinary services include:

Physician Consultations: Regular check-ups with your GP to monitor your condition and adjust treatments.
Allied Health Services: Access to services like physiotherapy, occupational therapy, podiatry, psychology, dietetics, and exercise physiology to support your overall health.
Nursing Support: Qualified nurses offer medication management, wound care, and patient education, ensuring you receive continuous support.

Medicare Benefits and Eligibility

If your GP develops a GPMP and TCAs, you may be eligible for Medicare benefits. This provides access to rebates for allied health services, such as physiotherapy or dietetics, related to managing your chronic condition. Key points to know:

Medicare rebates are available for up to five allied health services per calendar year.
If your allied health provider bulk bills, there will be no out-of-pocket cost. Otherwise, you may need to pay the difference between the provider’s fee and the Medicare rebate.
Unused allied health referrals can roll over to the next year but will still count towards the annual limit.
A new GPMP or TCAs isn’t needed every year, as long as your care plan remains relevant and necessary services continue.

Getting Started with Chronic Disease Management Program

To begin managing your chronic condition with our support:
Schedule an Appointment: Contact our clinic to book a consultation with one of our experienced GPs.

1. Comprehensive Assessment: During your initial visit, we’ll assess your health and medical history to understand your specific needs.
2. Develop a Personalised Care Plan: Based on the assessment, we’ll work with you to create a tailored GPMP and, if needed, TCAs to guide your treatment.
3. Ongoing Support and Review: We’ll continue to monitor your progress, provide regular reviews, and adjust your care plan as necessary to ensure optimal management of your condition.

Our dedicated team at The Village Black Rock is committed to supporting you in managing your chronic illness, empowering you to lead a healthier and more comfortable life. For more information or to book an appointment, please contact our clinic today.

Frequently Asked Questions

How do I get a Chronic Disease Management Plan?

Speak to your GP about your medical condition and whether a GPMP or TCAs are suitable for you. Your GP and practice staff will seek your consent before preparing the plan.

Do I need to pay for a Chronic Disease Management Plan?

If your GP bulk bills the service, there will be no out-of-pocket costs. If not, you may need to pay the difference between the GP’s fee and the Medicare rebate.

Can I get Medicare rebates for allied health services?

If you have both a GPMP and TCAs in place, you may be eligible for Medicare rebates for up to five allied health services per calendar year.

Do I need a new GPMP or TCAs every year?

No, you do not need a new plan each year. However, your GP will regularly review and update your plan as needed.

Can my GP share my plan with other healthcare providers?

With your consent, your GP may share relevant parts of your plan with other health professionals involved in your care.

How can I find out more?

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