Chronic disease management in general practice

What counts as a chronic condition

For care planning purposes, a chronic condition is one that has been present, or is likely to be present, for at least six months — or one that is terminal. There is no fixed list. Whether a structured plan would help is a clinical judgement made with the person, not a matter of matching a diagnosis to a register.

In practice the conditions most often planned for include diabetes, heart disease, high blood pressure, asthma and COPD, arthritis, chronic kidney disease, osteoporosis, chronic pain lasting more than six months, and long-term mental health conditions. Several conditions at once is common, and is often the reason a plan is worth making.

What changed in July 2025

Anyone who has had a care plan before may remember two separate documents: a GP Management Plan and a set of Team Care Arrangements. On 1 July 2025 both were replaced by a single document, the GP Chronic Condition Management Plan.

The practical effect is a simpler process. Referring someone to allied health no longer requires consulting two other providers first, and those providers no longer have to confirm the referral before the plan can be written. A referral is now an ordinary signed letter rather than a prescribed form.

Plans made before 1 July 2025 have not stopped working. Existing GP Management Plans and Team Care Arrangements continue to give access to services until 30 June 2027, though in practice most people move across to the new plan at their next annual review well before that.

What a plan actually contains

A care plan is a written document, and the person it belongs to gets a copy. Building it involves working through several things together.

• An assessment of health needs and how the condition is affecting daily life
• Goals for treatment and lifestyle, decided jointly rather than handed down
• The specific actions the person is going to take
• The treatments and services likely to be needed, including referrals
• A written plan with the steps set out and a date for review
• Consent to share relevant parts of the plan with the other clinicians involved

What the plan gives you

The most tangible benefit is access to subsidised allied health. With a current plan, Medicare contributes towards up to five individual allied health services in a calendar year — a physiotherapist, dietitian, podiatrist, exercise physiologist, psychologist or diabetes educator, for instance. Aboriginal and Torres Strait Islander people can access up to ten.

Two details are commonly misunderstood. The allowance is per calendar year, not per plan, and it is shared across all disciplines combined rather than five of each. And to keep that access, the plan needs to have been prepared or reviewed within the previous eighteen months.

Beyond the rebates, the plan does something less visible but arguably more useful: it gives every clinician involved the same written summary of what the person is working towards, and it creates a scheduled reason to come back and check progress rather than only being seen when something has gone wrong.

What happens at a care planning appointment

This is a long appointment, and it is worth booking it as one. The conversation covers the condition itself, how it is affecting work, sleep, mood and daily activities, what the person wants to be able to do that they currently cannot, and which other health professionals might help.

It helps to arrive with a list of current medicines including anything bought over the counter, the names of any specialists or allied health professionals already involved, recent test results if they were done elsewhere, and — most usefully — a sense of what matters most. A plan built around a goal the person actually cares about is followed; one built around a clinical target alone often is not.

Plans are usually reviewed at least once a year, and more often when things are changing.

Where it fits with the rest of your care

Care planning is designed around a usual general practice rather than a one-off visit. Access is through the practice a person is registered with under MyMedicare, or through the GP who provides the majority of their care.

That is not an administrative quirk. Most of the value in a care plan comes from continuity — someone who knows the history, notices when something has drifted, and holds the thread between the specialists, the allied health team and the person themselves.

When to seek help sooner

A planned review is not a reason to wait when something changes. Book sooner for new or worsening symptoms, medicines that have stopped working or are causing side effects, or if you have stopped taking something and have not said so. Low mood and loss of interest are worth raising too — depression is more common in people managing long-term conditions, and it is frequently the thing that makes everything else harder.

Some symptoms should not wait for any appointment. Chest pain or pressure, pain in the arm, shoulder, back, neck or jaw, shortness of breath, or feeling sick, sweaty or dizzy can be warning signs of a heart attack — and these less obvious symptoms are particularly common in women. If symptoms are severe, get worse, or last more than ten minutes, call Triple Zero (000) and ask for an ambulance.