CHRONIC DISEASE MANAGEMENT

The Chronic Disease Management (CDM) program works to engage with GPs, AHPs, practice nurses and practice staff to enhance chronic disease management and optimise preventative health strategies.

The program offers support, training and assistance with:

  • MBS Primary Care items e.g. health assessments, care plans, asthma and diabetes service incentive payments
  • Best practice guidelines and clinical support systems
  • The use of screening tools e.g. diabetes risk assessment tool (AUSDRISK), cardiovascular risk calculator
  • Coordinating patient care e.g. referral pathways
  • Quality Improvement activities that utilise the Pen CAT data extraction tool e.g. Putting Data into Practice initiative 

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.

If you have a chronic medical condition, you may be eligible for Medicare benefits if your doctor prepares the following plans for you.

Patients who have had, or are likely to have, a chronic condition for at least six months are eligible for a GP Management Plan (GPMP). Patients who also have complex care needs are also eligible for a Team Care Arrangement (TCA). The GP may be assisted by a practice nurse or other health professional in the preparation of these item numbers.

 

 

GP Management Plans are designed for patients who have complex conditions that require ongoing care, and a structured approach.

Your GP will determine if a plan is appropriate for you.

We offer care plans to all eligible patients who suffer from a chronic illness.

Patients are asked to book an appointment with their GP first to determine if they are eligible, and then an appointment will be made with the Practice Nurse who will complete the care plan.

COMMUNICATION & MESSAGES

INCLUDING VIA ELECTRONIC MEANS (EMAIL)

Contact Us

(03) 5744 1777
(03) 5744 2483 - FAX

Our Location

72 WOODS RD, 
YARRAWONGA, VIC 3730

Denis Medical Group

Our practice has policies & procedures in place to protect your privacy & confidentiality.  There are risks associated with some methods of electronic communication, such as email.  Please be aware that communication via electronic means may compromise your privacy and confidentiality.

Please do NOT use email to contact the practice in case of emergency.

If you are wanting to contact your Doctor, please contact our Practice Nurses during our opening hours and leave a message.  Your message will be triaged by our nursing staff and forwarded to the Doctor concerned and you will receive a response as soon as practicable.