Chronic Disease Management Long-term GP management and care plans for chronic conditions

From 1 July 2025, what was previously known as a Care Plan has been updated and is now referred to as the GP Chronic Condition Management Plan (GPCCMP). If you or a loved one lives with a chronic health condition expected to last six months or more, we encourage you to discuss creating a GP management plan with your regular doctor at Aloura Family Practice.

What is a GP Chronic Condition Management Plan?

A GP Chronic Condition Management Plan helps coordinate care for patients with long-term conditions such as diabetes, asthma, heart disease, kidney disease, arthritis and respiratory illnesses. The aim is to help you manage your condition effectively, prevent complications and maintain your quality of life.

Under a GP management plan, your doctor works with you to set realistic health goals and develop a structured plan that may include regular reviews, lifestyle recommendations and referrals to allied health professionals.

Conditions Supported Under Chronic Disease Management

Our doctors provide comprehensive chronic disease management for a wide range of long-term conditions, including:

  • Diabetes management and monitoring (including foot checks, blood sugar review and coordination of allied health support)
  • Asthma management, including lung function testing and action plans
  • Cardiovascular disease and hypertension
  • Chronic kidney disease
  • Metabolic and respiratory conditions

For example, a diabetes care plan supports regular monitoring, early detection of potential complications and coordination with podiatrists, dietitians and diabetes educators. Similarly, an asthma management plan helps patients recognise triggers, optimise medication use and reduce flare-ups.

Access to Allied Health Support

Your GP management plan may also include referrals for Medicare-rebateable allied health services such as physiotherapy, podiatry, dietetics, psychology and exercise physiology. For instance, a child with a speech delay may be eligible for up to five Medicare-rebateable speech pathology sessions under their GPCCMP.

Ongoing Reviews and Bulk Billing

Once a chronic disease management plan is in place, our doctors and nurses will review it every three months to track progress, update goals and adjust care as needed. All GPCCMPs and their reviews are bulk billed. If you’re unsure whether you qualify, our team can guide you through eligibility and next steps during your consultation.

Why Chronic Disease Management Matters

Coordinated care helps patients stay well for longer, avoid unnecessary hospital visits and maintain independence. Our doctors at Aloura Family Practice are dedicated to collaborating with you and your healthcare team to deliver personalised, structured care that meets your unique needs.

Frequently Asked Questions

A GP management plan (also called a GP Chronic Condition Management Plan) is a structured care plan designed for people living with one or more long-term medical conditions. It outlines your health goals, treatment strategies and any allied health services that may help you manage your condition effectively. Your doctor coordinates this plan with you and other members of your healthcare team.

You may be eligible for a chronic disease management plan if you have a condition that is likely to last for six months or longer, such as diabetes, asthma, heart disease, arthritis or chronic respiratory illness. Your doctor can confirm eligibility and discuss how a plan could support your ongoing care.

A GP management plan helps ensure that your care is well-coordinated and regularly reviewed. It also provides access to Medicare-rebateable allied health services, including physiotherapy, podiatry, dietetics, and psychology. This approach helps you stay on top of your condition, prevent complications and maintain your quality of life.

A diabetes care plan provides regular reviews and monitoring of your blood glucose levels, medication, and diet. It may also include foot checks to prevent complications such as neuropathy and referrals to allied health providers, including podiatrists and dietitians, for additional support.

An asthma management plan helps you understand your condition, identify triggers and manage flare-ups effectively. Your doctor will assess your symptoms, review your medications and create a written action plan that outlines what to do if your asthma worsens.

Once a chronic disease management plan is in place, your doctor and nurse will review it every three months. These reviews are essential for assessing progress, adjusting treatment if needed, and ensuring your plan continues to meet your health goals. All reviews are bulk billed at Aloura Family Practice.

Book an Appointment

If you or a loved one has a long-term health condition, our doctors can help you create a GP management plan tailored to your needs. Book your appointment online or call our reception to arrange a consultation at Aloura Family Practice in Canning Vale.

We’re here to support effective chronic disease management through personalised care, regular reviews and coordinated support from trusted health professionals.

Book Your Consultation Today