Chronic Disease Management

Chronic Disease Management

A Chronic Disease Management Plan or G Management Plan (GPMP) can help people with chronic medical conditions by providing an organised approach to care. A GPMP is a plan of action you have agreed to do with your GP. This plan identifies your health and care needs and sets out the services to be provided by your GP, and lists the actions you can take to help manage your condition.

As a patient, you may suffer from a chronic medical condition that has been (or is likely to be) present for six months or longer. (There is no list of eligible conditions), however, e.g, asthma, cancer, heart disease, diabetes, arthritis, COPD, Hypertension and stroke where a patient requires a structured approach to their health are all considered chronic. The GP is able to plan and coordinate the care of you, the patient with complex conditions that require the ongoing care from a multidisciplinary care team, such as physiotherapy, dietitian, podiatry or other allied providers. Your GP will determine whether a plan is appropriate for you and with your agreement arrange for you to visit practice.

With the above GPMP the GP may require you, the patient, to collaborate with at least two other health or care providers who will give ongoing treatment or services to you. Let your GP or nurse know if there are aspects of your care that you do not want to be discussed with other healthcare providers. These providers will be given a TCA or Team Care Arrangement instruction following your visit.

Once a plan is in place, you should be regularly reviewed by your GP. This is an important part of the planning cycle, where you and your GP check that your goals are being met and agree on any changes that might be needed.