Chronic disease management plans are designed by the patient, the GP and a nurse for patients who have complex chronic conditions requiring ongoing care. Chronic disease management plans allow our doctors and nurses to construct individualised “care plans” to coordinate your care needs. Anyone with a chronic condition is eligible for a chronic condition management plan. A chronic medical condition is one that has been present for at least six months or longer, such as:
- Cancer
- Cardiovascular disease
- Diabetes
- Osteoarthritis
- Osteoporosis
- Stroke
A chronic disease management plan can help people with chronic medical conditions by identifying personal goals and providing a structured approach to their care. It includes a plan of action you have agreed with your GP which is regularly reviewed and amended as required. This plan:
- Lists your chronic conditions
- Identifies your health and care goals and needs
- Sets out the services to be provided by your GP; and
- Lists the actions to be taken to help manage your conditions
