Chronic Disease Management

What is Chronic Disease Management?

The consulting doctors at Station Street Clinic, are committed to providing comprehensive care and support for patients living with chronic conditions. Through a multidisciplinary approach, patient education, regular follow-ups, collaboration, lifestyle modifications, and patient-centered care, the doctors and nurses aim to provide comprehensive support to those living with chronic diseases.

  • Multidisciplinary Approach: The doctors understand that chronic disease management requires a holistic approach. Your GP and practice nurse will work closely with you to develop personalised treatment plans, addressing not only the physical aspects of the disease but also the emotional and social elements. By considering your individual needs, lifestyle, and preferences, the doctors aim to create effective strategies for managing your chronic condition/s.

  • Education and Empowerment: Empowering patients through education is a key component of successful chronic disease management. Our practice nurses take the time to explain the nature of the condition, its underlying causes, and the importance of treatment adherence. The practice nurse will ensure that you have a thorough understanding of your condition and the necessary lifestyle modifications you may need to implement.

  • Regular Follow-ups: To ensure the effectiveness of treatment plans, the doctor or practice nurse will schedule regular follow-up appointments with the patient. These appointments allow the doctor to monitor the patient’s condition, assess treatment efficacy, and make any necessary adjustments to the management plan. the doctors are dedicated to closely tracking the progress of their patient and providing ongoing support.

  • Collaboration and Coordination: Managing chronic diseases often involves collaboration with other healthcare providers. The doctors and our practice nurses establish effective communication channels and coordination with specialists, allied health professionals, and community resources to ensure comprehensive care. Through this integrated approach, the doctors strive to optimise their patient's health outcomes and minimise the complications associated with chronic diseases.

  • Lifestyle Modification Support: In addition to medical intervention, the doctors emphasise the importance of lifestyle modifications in managing chronic diseases. Our practice nurses provide guidance on nutrition, physical activity, stress management, and smoking cessation. The practice nurses aim to empower patients to make positive lifestyle changes, which can significantly impact the course of their condition.

  • Patient-Centered Care: Above all, the doctors prioritise patient-centered care. Each patient's experience with chronic disease is unique, and the doctors strive to tailor their patient’s management plans accordingly. The doctors and practice nurses actively listen to their patients' concerns, address their questions, and involve them in shared decision-making. The goal is to ensure that patients feel respected, supported, and actively engaged in their own healthcare journey.

What is a Chronic Medical Condition?

A chronic medical condition is one that has been present for at least six months or longer, such as:

  • Asthma

  • Cancer

  • Cardiovascular disease

  • Diabetes

  • Musculoskeletal conditions

  • Stroke

Chronic Disease Management Plans

Chronic disease management plans are designed by general practitioners for patients who have complex conditions that require ongoing care, and a structured approach.

A GP 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 with your GP. This plan:

  • identifies your health and care needs;

  • sets out the services to be provided by your GP; and

  • lists the actions you can take to help manage your condition.

Team Care Arrangements

If you have a chronic medical condition and complex care needs requiring multidisciplinary care, your GP may also develop Team Care Arrangements (TCAs). These will help coordinate more effectively the care you need from your GP and other health or care providers.

TCAs require your GP 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 discussed with other health care providers.

Regular Reviews

Once a plan is in place, it 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.

The consulting doctors offer care plans to all eligible patients who suffer from a chronic illness with little or no cost to the patient.

Patients are asked to book an appointment with their GP to determine if they are eligible. Our practice nurse will provide support and monitoring between visits to your GP.