Chronic Condition Management Plans

Hamilton Medical Group supports patients living with chronic health conditions through structured, ongoing care focused on managing symptoms, reducing the risk of complications and supporting quality of life. Our GPs provide ongoing care for a range of chronic conditions, including diabetes, heart disease, high blood pressure, asthma, chronic respiratory disease, arthritis and many others.

What is a Chronic Condition Management Plan?

A Chronic Condition Management Plan (CCMP) helps GPs plan and coordinate care for patients living with a chronic or terminal medical condition. The plan provides a structured approach to ongoing care, with a focus on managing symptoms, reducing the risk of complications and supporting quality of life.

A CCMP can outline your health goals, recommended treatments, ongoing management needs and referrals to other health professionals or allied health providers where appropriate.

Under Medicare requirements, a Chronic Condition Management Plan is prepared by your usual medical practitioner. This is generally a GP who has provided most of your care over the previous 12 months, or a GP who is expected to provide most of your care over the following 12 months. A GP at the same medical practice may also prepare the plan where they meet these requirements.

For patients registered with Hamilton Medical Group through MyMedicare, GP Chronic Condition Management Plan preparation and review services must be provided through the practice where they are registered. These services can be provided by an eligible GP at the registered practice and are not limited to the patient’s nominated or preferred GP.

Our practice nursing team can assist the GP with preparing the plan, including gathering relevant information and supporting the assessment process. The GP remains responsible for reviewing and confirming the plan and discussing it with you.

What is a Chronic Condition?

For the purposes of Medicare Chronic Condition Manager, a chronic or terminal condition is one that has been, or is likely to be, present for at least six months. A terminal medical condition may also meet the eligibility requirements.

Examples of chronic conditions include diabetes, asthma, heart disease, arthritis and chronic respiratory conditions. Patients with terminal conditions may also be eligible for Chronic Condition Management services.

What does a Chronic Condition Management Plan involve?

A Chronic Condition Management Plan can involve coordinated care between your GP and other health professionals, such as a Diabetes Educator and Dietitian, Podiatrist, other allied health professionals and visiting specialists. This team-based approach can help coordinate the different aspects of your ongoing care.

Regular monitoring is an important part chronic disease management. Our doctors and nurses work with patients to monitor progress, review treatment and support lifestyle changes that may improve long-term health and wellbeing. This may include guidance on nutrition, physical activity, medication management and reducing risk factors for further complications.

We also place a strong emphasis on patient education, helping you understand your condition and feel more confident managing your health day to day. Our team works collaboratively with patients to establish realistic and achievable health goals.

Your Chronic Condition Management Plan can be reviewed as your health needs change and as part of your ongoing care. Where appropriate, your GP will discuss the timing of reviews with you based on your individual circumstances and care needs.

Where and how do I make an appointment?

Chronic Condition Management Plan appointments are provided at Hamilton Medical Group and can be arranged through our reception team.

These plans are conducted by Practice Nurses at the Hamilton Medical Group in conjunction with your GP. Patients wishing to have a Chronic Condition Management Plan need to speak to their GP and be referred by before making an appointment.

We currently have five nurses involved with the Chronic Condition Management Plan program at the Hamilton Medical Group. The nurses are Aliesa, Lyn, Shaylee, Rowena and Vicki.