Chronic Disease Care

eneral Practitioner Management Plans (GPMPs)

If a patient has a chronic or terminal medical condition, their General Practitioner may recommend preparing a General Practitioner Management Plan (GPMP).

A GPMP provides a structured and coordinated approach to managing ongoing health needs. It is developed in partnership between the patient and their GP, and may include:

• Identification of health and care needs

• Planned health goals and treatment priorities

• A list of services to be provided by the GP and other healthcare professionals

• Agreed actions to support the management of the condition

This plan ensures that care remains organised, collaborative and focused on long-term health and quality of life.

All medical services are provided in accordance with AHPRA and RACGP standards. This information is general in nature and does not replace individual medical advice.

Chronic medical conditions and complex care needs may require multidisciplinary care. General Practitioners may also develop a Team Care Arrangements (TCAs). This will help coordinate the care required more efficiently.

TCAs require GPs to collaborate with at least two other healthcare providers who will give ongoing treatment and services.

Once a plan is in place, regular reviews are important for the planning cycle of care, where goals are set and met and whether should be considered.

The review also offers the opportunity to further discuss any general issues and concerns.

If both the GPMP and TCAs are prepared for by a General Practioner, patients may be eligible for Medicare rebates for specific individuals and Allied health services that have been identified as part of the care plan. The need for these services must be directly related to the chronic medical (or terminal) condition.

A Mental Health Treatment Plan is a plan for people with a mental health disorder.

The plan identifies what type of health care is needed and spells out what has been agreed upon and aims to achieve.

If a patient has a Mental Health Treatment Plan, they are entitled to Medicare rebates. This gives the patient access — subsidised by Medicare — to certain psychologists, occupational therapists, and social workers.

After the first 6 appointments, doctors need to you need to review the mental health plan and will decide if further sessions are required and need to be referred.

The Annual Cycle of Care is a checklist designed to help patients and the healthcare team keep diabetes care on track.

Diabetes can lead to complications that affect the kidneys, eyes, feet and heart. The Annual Cycle of Care can help identify further health concerns early and allow for the best treatment with the healthcare team.

Plans involve:

Every 6 months:

• Measure weight and height and calculate body mass index
• Measure blood pressure, for someone with diabetes, the target BP is 130/80 to 140/90 or less.
• Examine feet to assess blood supply and sensation

Once a year:

• Assess diabetes control by measuring HbA1c which shows an average of your blood glucose level over the past 10-12 weeks, and where the general target level is 7% (53 mmol/mol) or lower.
• Measure total cholesterol, triglycerides and HDL cholesterol
• Test for microalbuminuria

Once every 2 years:

• Ensure that a comprehensive eye examination is carried out
• Review diet
• Review levels of physical activity
• Check smoking status
• Review medication

The Asthma Cycle of Care involves at least two asthma related consultations within 12 months for a patient with moderate to severe asthma.

The Asthma Cycle of Care includes:

• Document diagnosis and assessment of the severity and the level of control needed for asthma
• Review the patient’s use of, and access to, asthma-related medication and devices
• Provide a written asthma action plan
• Provide asthma self-management education
• Review the written or documented asthma action plan