Chronic Disease Management Camberwell
Structured, ongoing GP care to help you understand your condition, work towards meaningful health goals and coordinate support across your healthcare team.
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A coordinated approach to living with a chronic condition.
Chronic conditions often benefit from regular monitoring and a clear plan rather than isolated appointments. Your GP can work with you to understand your condition, identify priorities and coordinate the healthcare professionals involved in your treatment.
Care is personalised to your diagnosis, symptoms, medicines, lifestyle, other health conditions and the outcomes that matter to you.
Practical support for long-term health.
Your care may involve assessment, planning, monitoring, preventive healthcare and referrals.
Health review
- Medical history and symptoms
- Medicines and test results
- Personal priorities and risks
Care planning
- Clear health goals
- Treatment and self-management steps
- Responsibilities across the care team
Coordinated care
- Allied health referrals when eligible
- Specialist and community services
- Nursing and pathology support
Ongoing review
- Progress monitoring
- Medicine and treatment review
- Plan updates when needs change
Care for a wide range of ongoing health concerns.
A chronic condition is assessed individually. Having a diagnosis does not automatically mean a particular plan or referral is suitable.
Cardiovascular and metabolic health
Ongoing care may support diabetes, high blood pressure, high cholesterol, heart disease and related risk factors.
Respiratory conditions
Regular review can help manage conditions such as asthma and chronic obstructive pulmonary disease, including symptoms, medicines and action plans.
Musculoskeletal conditions
GP care can support arthritis, persistent pain, osteoporosis and mobility concerns, with referrals considered when clinically appropriate.
Other long-term conditions
Care may also support neurological, kidney, gastrointestinal, autoimmune and other ongoing conditions requiring structured monitoring.
A structured plan developed with your GP.
From 1 July 2025, the GP Chronic Condition Management Plan replaced the previous GP Management Plan and Team Care Arrangements for new plans.
What the plan can include
Your GP works with you to document your condition, treatment and management goals, the actions you can take, the care your GP will provide and the roles of other healthcare professionals where multidisciplinary care is needed.
Allied health referrals
Eligible patients whose condition would benefit from multidisciplinary care may be referred for Medicare-supported allied health or other primary care services consistent with their plan. Your GP determines whether referrals are clinically appropriate and discusses available options with you.
Reviews and continuity of care
Plans should be reviewed so progress, goals and treatment can be updated. MyMedicare-registered patients generally access plan preparation and review through their registered practice; patients who are not registered access these services through their usual GP, subject to Medicare requirements.
What to expect when discussing ongoing care.
Your GP will review your current conditions, symptoms, medicines, recent tests and the healthcare professionals already involved. Together, you can identify realistic goals and decide whether structured care planning would benefit you.
Bring an up-to-date medicine list, relevant specialist letters or test results, and details of any allied health professionals you currently see. A longer appointment may be required for care planning.
Before booking
Call reception if you are requesting a chronic condition management plan or review so the team can arrange an appropriate appointment type and explain any preparation.
Your GP remains at the centre of your care.
Good chronic condition management brings together treatment, prevention and practical self-management.
Monitoring and tests
Depending on your condition, care may include examination, blood pressure checks, pathology, imaging, symptom tracking and other monitoring.
Medicines
Your GP can review how medicines are working, check for side effects or interactions and coordinate changes with specialists where required.
Lifestyle and self-management
Plans may include achievable steps involving nutrition, movement, sleep, smoking cessation, alcohol intake, mental wellbeing and recognising changes that need medical review.
Confirm eligibility and costs before your appointment.
Eligibility for Medicare-supported chronic condition management and allied health services depends on current MBS requirements and your individual clinical circumstances.
Mixed billing practice
Reception can explain the clinic’s current fees, Medicare eligibility and any potential out-of-pocket costs for your appointment.
Explore related services.
Discuss ongoing care with your GP
Book online or call reception for help selecting the appropriate appointment.
