Chronic Disease Management
If you live with a long-term health condition such as diabetes, heart disease, asthma, arthritis or a mental health condition, Family Doctor GPs can help you manage it through a GP Management Plan (GPMP) and Team Care Arrangements (TCA) — Medicare-subsidised care plans that coordinate your care and give you access to allied health services.
GP Management Plans (GPMP)
A GP Management Plan is a structured written plan prepared by your GP (MBS item 721) that documents your chronic conditions, goals, management strategies, and how your care will be coordinated. It is suitable for anyone with at least one chronic or terminal medical condition that has been (or is likely to be) present for 6 months or longer.
Preparing a GPMP typically takes a long consultation (30–45 minutes). The plan is reviewed every 3 months. Many Family Doctor clinics bulk bill care plans for eligible patients — contact your nearest clinic to confirm.
Conditions We Can Manage Under a Care Plan
- Type 1 and type 2 diabetes
- Heart disease, high blood pressure, and high cholesterol
- Asthma and chronic obstructive pulmonary disease (COPD)
- Osteoarthritis, rheumatoid arthritis and chronic pain
- Chronic kidney disease
- Mental health conditions (anxiety, depression, bipolar)
- Stroke and post-stroke rehabilitation
- Cancer care and survivorship
- Obesity and metabolic syndrome
- Osteoporosis
Team Care Arrangements (TCA) — Allied Health Access
If you have a GP Management Plan and need care from other health professionals, your GP can prepare a Team Care Arrangement (MBS item 723). This gives you access to up to 5 Medicare-subsidised allied health visits per calendar year — including podiatry, dietetics, physiotherapy, exercise physiology, psychology, diabetes education, and more.
The 5 visits are shared across all allied health disciplines combined. Medicare rebates cover most of the cost; some providers bulk bill.
Diabetes Care at Family Doctor
Our GPs offer comprehensive diabetes management including HbA1c monitoring, foot checks, eye check referrals, kidney function tests, lifestyle counselling, and medication management. We coordinate with diabetes educators, dietitians, endocrinologists, and podiatrists through Team Care Arrangements. Many clinics have a diabetes cycle of care protocol to make sure nothing is missed.
Heart Disease and Hypertension
Long-term management of heart disease and high blood pressure involves regular blood pressure monitoring, cholesterol checks, medication adjustment, lifestyle support, and cardiologist referrals when needed. Your GPMP ensures regular reviews so your care is proactive, not reactive.
Asthma, COPD and Respiratory Conditions
We offer spirometry (lung function testing), asthma action plans, COPD management plans, inhaler technique reviews, flu and pneumococcal vaccinations, and respiratory physician referrals. Good asthma and COPD control means fewer flare-ups and hospital admissions.
Mental Health as Part of a Care Plan
Mental health conditions like chronic anxiety and depression can be managed under a GPMP alongside a Mental Health Treatment Plan. This gives you both Medicare-subsidised psychology sessions AND allied health visits through your Team Care Arrangement. See our mental health page for more.
Medicare-Subsidised Reviews and Follow-Up
Your GPMP is reviewed every 3 months (MBS items 732, 737) and the Team Care Arrangement is reviewed at the same time. Reviews are important because your condition, medications, and goals can change. Many Family Doctor clinics bulk bill GPMP reviews for eligible patients.
Find a Family Doctor Clinic Near You
With over 114 clinics across Australia, a Family Doctor GP is ready to help you manage your chronic conditions. Use our clinic finder to locate your nearest clinic and book a long consultation to discuss a care plan.
Frequently Asked Questions
What is a GP Management Plan?
A GP Management Plan (GPMP) is a structured written plan your GP prepares for you if you have a chronic condition. It documents your conditions, goals, and management strategy. It is a Medicare item (721), and at most Family Doctor clinics it is bulk billed for eligible patients.
Do I pay for a care plan?
Medicare covers the cost of preparing a GPMP. Whether there is an out-of-pocket cost depends on your clinic’s billing policy — most Family Doctor clinics bulk bill care plans for eligible patients. See our bulk billing page for confirmed bulk-billing clinics.
How often are care plans reviewed?
Every 3 months (MBS items 732 and 737). Regular reviews are important because your condition, medications, and goals can change. A review is a shorter consultation than the initial plan and is also bulk billed at most Family Doctor clinics.
Can I see a dietitian or physio on a care plan?
Yes — through a Team Care Arrangement (MBS 723) that your GP prepares alongside your GPMP. This gives you up to 5 Medicare-subsidised allied health visits per calendar year, shared across all disciplines (podiatry, dietetics, physio, exercise physiology, psychology, etc.).
Do I need a referral for each allied health visit?
Your GP prepares one Team Care Arrangement referral per year that covers all allied health visits within it. You do not need a new referral for each visit, but you do need to see the same provider listed on the TCA. If you need to switch providers, your GP can update the TCA.
