Chronic disease and lifestyle.
Managing an ongoing health condition well is about small, consistent steps over time. Your GP is the coordinator, keeping the plan on track, watching for what changes, and looping in specialists and allied health where useful. Available across all three SMSG centres.
Steady care, over time.
GP Chronic Condition Management Plans (GPCCMPs) are Medicare-funded structured plans for patients with a chronic health condition. They provide a written framework for managing your condition, coordinating care between your GP and other providers, and reviewing progress at set intervals. A GPCCMP opens access to partially Medicare-rebatable allied health sessions, which is particularly valuable when a dietitian, physiotherapist, psychologist or podiatrist is part of the picture.
Conditions commonly managed under a plan include diabetes, asthma, chronic obstructive pulmonary disease (COPD), heart disease, chronic kidney disease, mental health conditions, arthritis, and other long-term illnesses. For conditions that need specialist input, referral pathways to Excelsia Specialists Centre are coordinated by your GP.
Care plans, quit support, and steady review.
Coordinated, not siloed.
Diabetes. Management is coordinated between your GP and, where relevant, an endocrinologist, dietitian, and other allied health. Care includes regular monitoring of glucose, cholesterol, kidney function, eyes, feet, and cardiovascular risk. Medications are adjusted according to your condition and progress. The endocrinologist at Excelsia Specialists Centre is available to provide specialist support for your diabetes management and ongoing care. Prevention and reversal of pre-diabetes with weight, diet, exercise and, where appropriate, medication can substantially reduce risk of progression.
Asthma and COPD. Both involve airway inflammation and are managed with a combination of medication, avoiding triggers, and monitoring lung function. Your GP confirms the diagnosis with spirometry where relevant, establishes a medication plan, prepares an Asthma Action Plan or COPD Action Plan, reviews control at set intervals, and adjusts treatment as your condition evolves. If considered appropriate, a Respiratory and Sleep Medicine Physician at Excelsia Specialists Centre can be involved and coordinate with your GP to provide comprehensive care in your health journey.
Medications review. Reviewing medications regularly is part of good care. Multiple medications can interact, some may no longer be needed, and some may benefit from a different dose or timing. Your GP can review during a routine appointment, or a formal Home Medicines Review can be arranged. That involves an accredited pharmacist visiting you at home, followed by a written report to your GP, who then discusses findings with you. Medicare-funded for eligible patients.
Across all three centres.
Chronic disease and lifestyle care is available with any SMSG GP at any of our three centres, with coordinated allied health support where needed.
Confirmed at booking.
GP Chronic Condition Management Plans and reviews, and Home Medicines Reviews are Medicare-funded services. Standard consultations for chronic disease management follow the individual practitioners' billing arrangement.
Allied health services can be accessed through a GPCCMP referral, with patients eligible to receive Medicare rebates up to their applicable annual entitlement. Private fees apply to all allied health appointments within SMSG, with Medicare rebates available where eligible. Reception will confirm the applicable fee and rebate arrangements with patients during the booking and check-in processes.
Common questions.
Do I need a referral for a GP Chronic Condition Management Plan?
No. Plans are prepared by your GP directly. You need to have an eligible condition and typically an established relationship with the practice.
How often is the plan reviewed?
Plans are reviewed at defined intervals, typically every 3 to 6 months, depending on your condition.
Can I access allied health without a GPCCMP?
Yes, patients can see allied health practitioners privately without a referral. A GPCCMP referral provides access to up to 5 allied health sessions per year, with eligible patients able to receive Medicare rebates for these sessions.
Can I get help to quit smoking without a GPCCMP?
Yes. Smoking cessation support can be provided in a standard consultation with your GP, and Quitline is a free national resource on 13 78 48.
Who prepares a Home Medicines Review?
Your GP refers to an accredited pharmacist. The pharmacist visits you at home and prepares a report for your GP to act on.
