Chronic disease management Care Plans and Health Checks

Care plans play a vital role in providing effective and person-centred care. They serve several important purposes: Coordination and Continuity: Care plans facilitate coordination among healthcare professionals and caregivers involved in an individual's care.

GP Management Plans and Care Plans

If you possess a persistent medical ailment, you may qualify for the following services:

  • General Practitioner Management Plan (GPMP)
  • Team Care Arrangements (TCAs)
  • Mental Health Case Conferences (MHCC).
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Chronic medical conditions are those that have persisted for a minimum of 6 months. This includes asthma, cancer, cardiovascular disease, diabetes, kidney disease, musculoskeletal conditions, and stroke.

These care plans coordinate healthcare and diminish the necessity for spontaneous consultations. They are instrumental in documenting comprehensive, precise, and current information regarding a patient’s condition and treatment.

Crafting a care plan assists in managing your health and empowers the advancement of treatment.

Is a GP management plan (GPMP) the same as a care plan?

While GP Management Plans (GPMPs) focus on care plans managed by a single GP, Team Care Arrangements (TCA) are available when a multidisciplinary approach involving other healthcare providers is required. These care plans outline treatments, appointments, and address the patient’s healthcare needs, health issues, and relevant conditions.

Currently, about 50% of GP consultations involve patients with chronic diseases such as heart disease, cancer, or diabetes. GPMPs, developed under the Medicare Benefits Scheme, provide a structured approach to managing chronic conditions. The goal is to help healthcare providers and allied health professionals plan and coordinate care, improving patient outcomes and reducing the need for frequent, unscheduled visits or unnecessary hospitalizations.

A GPMP ensures that a patient’s condition and treatment plan are accurately and comprehensively recorded, encouraging patients to take an active role in managing their health—essential for effectively addressing chronic conditions.

Patients can better understand their condition and how to manage it 

When patients have a clearer understanding of their condition, it significantly enhances their health outcomes. Providing patients with more information and support about their condition empowers them to take an active role in managing their treatment. Care plans facilitate this by involving the patient in the development process, securing their agreement, and providing them with a copy of the plan. This approach empowers patients with knowledge and outlines the best steps they can take to manage their health effectively.

Supporting better coordinated care 

Care plans improve coordination among practitioners and allied health services involved in a patient’s care. While GP Management Plans (GPMPs) concentrate on care managed by a single GP, Team Care Arrangements (TCA) come into play when a multidisciplinary team is needed to address a condition. These plans detail treatments, appointments, and the patient’s healthcare needs, conditions, and management goals. They also outline specific actions for the patient, ongoing treatments and services necessary, and arrangements for delivering and reviewing the plan every three months.

This structured approach enables better planning and management of care compared to reactive, ad hoc visits that occur when a patient’s condition deteriorates. A future of care supporting better patient outcomes 

Care plans promote positive outcomes for both patients and GPs by providing long-term management of chronic conditions. These types of plans do this by providing multiple benefits, including securing patient involvement in their own health outcomes, providing a structured plan for better health planning, better coordination of treatment, all while reducing the strain on both GPs and the health system.