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Chronic Disease Management

What is Chronic Disease Management?

The consulting doctors at Box Hill Medical Centre, 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: We understand that chronic disease management requires a holistic approach. Your GP and 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, we aim to create effective strategies for managing your chronic condition/s.

  • Education and Empowerment: We believe that empowering patients through education is a key component of successful chronic disease management. Our nurses take the time to explain the nature of the condition, its underlying causes, and the importance of treatment adherence. We 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, we schedule regular follow-up appointments with our patients. These appointments allow us to monitor their condition, assess treatment efficacy, and make any necessary adjustments to the management plan. Our healthcare providers are dedicated to closely tracking the progress of our patients and providing ongoing support.

  • Collaboration and Coordination: We recognize that managing chronic diseases often involves collaboration with other healthcare providers. Our team establishes effective communication channels and coordination with specialists, allied health professionals, and community resources to ensure comprehensive care. Through this integrated approach, we strive to optimise our patients' health outcomes and minimise the complications associated with chronic diseases.

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

  • Patient-Centered Care: Above all, we prioritise patient-centered care. We understand that each patient's experience with chronic disease is unique, and we strive to tailor our management plans accordingly. We actively listen to our patients' concerns, address their questions, and involve them in shared decision-making. Our goal is to ensure that our 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.

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

If you have any queries about Chronic Disease Management, please call us on 03 5941 1611.

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