Care Management

What are Chronic Disease Management & Care Plans?

A chronic disease is a medical condition that has been, or likely to be, present for six months or longer or is terminal. 

Care plans are organized sets of interventions focused on a structured approach to management & care of chronic diseases for overall wellbeing. 

Who will Prepare a Care Plan?

Your physician (or any GP) will prepare the care plan so they can: 

  • Better manage your disease with the assistance of allied health professionals 
  • Tailor the plan to your needs in partnership with a multidisciplinary healthcare team  
  • Help you choose an appropriate plan that has better coverage and superior services

Why are Care Plans Needed?

Care plans are necessary as they: 

  • Enable you to decide on the most suitable providers and services
  • Provide an opportunity to decide on the ideal treatment
  • Give easy access to allied health service providers 
  • Help you best manage & care for your disease 
  • Support you to achieve your long-term health goals 

Types of Chronic Disease Management & Care Plans 

There are two types of plans for chronic disease management and care. 

GP Management Plan (GPMP)
GPMP is a plan of action agreed on between you and your GP. It provides an organized approach to disease care by: 

  • Identifying your medical care needs
  • Setting out the services to be provided by your GP and others
  • Listing the actions you need to take to manage your condition

Team Care Arrangement Plan (TCAP)
This plan is recommended if you require treatment from two or more health professionals. The plan lets your GP work with, and refer you to, other healthcare providers including allied health workers who may offer you treatment or services.

Protocol for Preparing the Care Plan

To begin, you will need to discuss your eligibility with the GP before seeking the care plan. Your eligibility for a plan depends on:

  • Clinical judgment of the GP, who takes into account your medical condition
  • Your care needs and the general guidance set out by the plan provider 

If you are deemed eligible, you will make an appointment with your practice nurse who will guide you through the plan, and then with the GP to prepare the plan. 

Offer and Acceptance of Care Plan

Once the plan is ready, the GP or the practicing nurse will call you to discuss the plan offer, agreement and acceptance. If you accept the plan, it will be documented in writing, kept in a file at your GP’s practice and a copy will be given to you. 

How is the Care Plan Helpful?

The care plan can help you pay for:

  • Doctor visits, lab tests, prescription medicines, preventive care
  • Behavioral health services, rehabilitation programs, hospital care

Review of Care Plans 

You are required to review your plan regularly with your GP to assess whether it is working for you or if any changes are needed. 

Benefits of Chronic Disease Management & Care Plans

The major benefits include:

  • Enhanced service accessibility 
  • Minimal out of pocket expenses 
  • Reduced hospital utilization
  • Better health outcomes
  • Improved quality of life