Chronic Disease Management - GP and Team Care Plans
Our aim is to work with you in developing a plan of care to manage your chronic medical condition/s. Patients with chronic or terminal medical conditions such as cancer, diabetes, hypertension, osteoporosis, arthritis, chronic pain, asthma, lung disease are eligible for a GP Management Plan (care plan). Eligibility is determined by the GP.
The Care Plan provides management goals & identifies actions that you can take to improve your health. Further treatment and ongoing services are also identified to manage your care.
If ongoing care is needed by allied health professionals, you may also be eligible for Team Care Arrangements. These allow access to certain individual allied health services on referral from the GP e.g. podiatrist, dietitian, physiotherapist, exercise physiologist.
You will be given a copy of the care plan and be reviewed periodically by your GP to make changes and improvements in your care management as required. With your participation and the support of available services, we plan to provide optimal care in the management of your chronic disease.
DVA Gold Card Holders - Chronic Disease Management - CVC Program
The CVC program uses a proactive approach to improve the management of chronic disease and quality of care for DVA patients on a Gold Card. Eligibility is determined by the GP according to the DVA guidelines.
The GP and a nurse coordinator work with the participant (and their carer if applicable) to manage ongoing care. The objective is for the participant to become healthier with less need to be admitted to hospital plus be better educated and empowered to self-manage their conditions.
A nurse will visit the home once a year to make an assessment of physical and mental condition. The nurse will phone the participant monthly and will coordinate treatment services and create a plan of care in conjunction with the GP. Regular consultations with the GP are encouraged and any issues will be addressed to improve quality of care.