Chronic Disease Management

Individualised Chronic Disease Management Support and Care Plans

At GPs on Curzon, all our doctors are passionate about helping our patients if they have a chronic disease.

Chronic diseases can be a part of someone’s life, but they can generally be managed, and hence we aim for improvement in a person’s health.

A chronic medical condition is one that has been (or is likely to be) present for six months or longer.

Examples of Chronic diseases include cardiovascular disease (like Angina, Heart Attacks and Strokes) Asthma, Significant Osteoarthritis, Osteoporosis, Rheumatoid arthritis, or Diabetes.

Our GPs and Nurses understand that navigating a chronic disease and all the recommended testing, medications and follow up, can be overwhelming, difficult and at times confusing. We are here to help. With our expertise in coordinating care and our contacts within Toowoomba, we can match the right allied health practitioners and services to your individual needs.

This can be improved with the help of a “Chronic Disease Care Plan”. A chronic disease management plan enables your GP to plan and coordinate your health care. This can assist you in gaining access to services that are required for ongoing maintenance of your health issues who require multidisciplinary, team-based care.

Our Doctors with a Special interest in Chronic Disease Management

All our doctors have education in Chronic Disease management.

Our new doctors, in particular Dr Bridget Steer, Dr Annabelle Franklin and Dr Gabriel Rodrigues are available at short notice to assist with your condition.

To book your chronic disease management consultation today:

Call us at 07 4633 9000 to book an appointment. Online bookings are unavailable for this particular service, as it includes an appointment with both nurse and doctor.

Chronic Disease Management FAQs

A GP Management Plan is a written plan of management developed by your GP and practice nurse in consultation with you. The GP Management Plan is a written set of information about what you need in managing your chronic or complex condition.

Any person with a chronic (long term) medical condition, such as:

  • Diabetes
  • Asthma
  • Arthritis
  • Cancer
  • Heart Disease
  • Osteoporosis

Together we:

  • Identify your health priorities
  • Identify your goals for your health
  • List the actions you can take to help manage your condition
  • What (if any) other health care and community services you need
  • What results you would like from the GPMP to help with your chronic condition
  • Team Care Arrangements

If your doctor determines you would benefit from other health care providers or allied health professionals being involved in providing treatment, a team care arrangement will be completed. With your consent, your doctor or practice nurse will ask the relevant allied health professionals to be part of your care plan.

Any allied health worker like a physiotherapist, dietitian, podiatrist, audiologist, diabetes nurse, occupational therapist, pharmacist, optometrist, or exercise physiologist.

Persons with a GP Management plan and Team Care Arrangement are eligible for 5 visits per calendar year to see allied health professionals with Medicare support.

All GPMP and TCA plans are bulked billed by your GP if you have a Health care card or Pension card.

Some Allied health professionals may require you to pay on top of the Medicare rebate. Speak to your allied health professional about any charges.

Once a plan is in place, it should be regularly reviewed by your GP and a practice nurse. This is an important part of the plan cycle, where you with your GP and practice nurse check that your goals are being met and agree on any changes that you may require.

A GP Management Plan Review is usually undertaken every 3-6 months.

All GPMP Reviews are bulk billed by your GP if you have a Health Care card or Pension card.


The GP management plan will take about 45-60 minutes of your time. Your doctor and practice nurse will spend this time consulting with you to prepare your care plan.

Your GP will decide if you fulfil the eligibility requirements set by Medicare, prior to preparing a plan.

Medicare has guidelines on who can and can’t have a GP Management Plan prepared. Your GP will help in making this decision.

If you are visiting an allied health professional, please contact their number to make an appointment.

If you have any questions, ask your doctor or practice nurse

  1. Get a copy of your GP Management Plan (GPMP) / Team Care Arrangement (TCA).
  2. Book your appointments with your allied health team.
  3. After 4-6 months, book a GPMP Review / TCA Review with your GP and practice nurse.
  4. Book any further appointments with your allied health professional. If you have a TCA, you get up to 5 visits with an allied health professional in a calendar year. You can always see your allied health professionals more often privately if you wish.
  5. Continue with the recommendations made in your GP Management Plan.
  6. After 4-6 months, book another GPMP Review / TCA Review with your GP and practice nurse to discuss the ongoing treatment.