Chronic disease management

Chronic disease management

What is a chronic medical condition?

Chronic disease is an ongoing health condition or illness with persistent effects that can be controlled but not cured. Chronic disease often has significant, negative impact on the lives of individuals and their families.

Chronic Disease Management

Chronic disease management is the responsive, person centered planning and coordinating of health care for a patient that has one or multiple chronic diseases. The disease management for chronic conditions is undertaken by health professionals working in partnership with the patient. This can include monitoring, coaching motivation and educational support. The health professional’s work together with the patient to support person centered goals. To achieve improvements in health related quality of life, coordination, consistency and continuity care is the aim of all chronic disease management.

Chronic Disease Management aims to plan and coordinate the health care of patients with chronic or terminal medical conditions, including patients with these conditions who require multidisciplinary, team-based care from a GP and at least two other health or care providers.  Our focus is on:

  • Improving the health and wellbeing of our patients
  • Supporting vulnerable people with complex and chronic disease who are at risk of hospitalisation
  • Potentially reduce hospital admissions, readmissions and emergency department (ED) presentations by improving patient outcomes (clinical and social)
  • Promote awareness, understanding and knowledge about care coordination and its benefits to people living with complex or chronic disease

A Chronic Disease Team will work with you to create a personalised management plan. Your doctor is able to offer GP management plans, GP mental health plans and team care arrangements. This provides access to services to other independent allied health practitioners. To find out if you qualify for one of our management plans, please make an appointment with your doctor. Nursing staff are able to assist with the development and implementation of a management plan.

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Mornington VIC 3931

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