Chronic Disease Management

Our team of specialist GPs are passionate about identifying and helping patients treat chronic medical conditions. We support patients with preventative health measures that can help reduce the risk of chronic disease impacting your life.

We’re experienced in working with patients to help formulate Chronic Disease Management Plans and Team Care Arrangements for patients who have complex conditions that require ongoing care in a structured way.

A Management Plan helps formalise a plan of action you have agreed with your GP, by identifying your health and care needs, setting out the services to be provided by your GP, and listing the actions you can take to help manage your condition.

Team Care Arrangements can support the management of chronic medical conditions and complex care needs requiring multidisciplinary care. This can help you coordinate care from your GP and other healthcare providers.

Chronic disease management services include:

• Diabetes
• Heart failure
• Ischaemic heart disease
• Chronic kidney disease
• Hypertension / high blood pressure
• Hyperlipidaemia / high cholesterol
• Depression
• Asthma
• Chronic obstructive pulmonary disease
• Osteoarthritis
• Osteoporosis
• Autoimmune conditions