Chronic Disease Management in Werribee

Living with a long-term condition means more than a script every few months. Diabetes, heart disease, asthma, COPD and arthritis all need regular monitoring, adjustments to treatment, and often input from several health professionals. Without coordination, things get missed. A test isn’t repeated, a referral lapses, or nobody checks how the new medication is going.

Chronic disease management with our GPs gives your care a structure. You’ll have a plan, a schedule of reviews and a doctor who keeps track of the details.

Your GP Chronic Condition Management Plan

If you have a condition that has lasted, or is expected to last, six months or more, your GP can prepare a GP Chronic Condition Management Plan. This sets out your goals, treatment and who is involved in your care. Eligible patients can also access Medicare rebates for up to five allied health visits each calendar year, for example with a dietitian, physiotherapist or diabetes educator.

Your plan is reviewed regularly, so it reflects how you’re actually going rather than how things looked a year ago. Our article on working with your GP to manage a chronic condition explains the process in more detail.

Support Under One Roof

• GPs with interests in chronic disease, cardiovascular and metabolic health

• A diabetes educator and dietitian among our allied health team

• A consultant cardiologist, Dr Muhammed Aydin, consulting from the clinic

• 4Cyte Pathology on site for regular blood tests

• Reminders and recall, so reviews don’t slip

More detailed clinics are being developed as part of our subspecialty clinic model.