Chronic Disease Management in Wollongong
Our GPs at Illawarra General Practice provide ongoing care for people living with long-term health conditions, such as diabetes, heart disease, asthma, COPD and arthritis. We see patients from Wollongong and across the Illawarra, and work with you, our practice nurses, allied health professionals and specialists to plan and coordinate your care.
Consultations and GP care plans are bulk billed for patients with a valid Medicare card.
What is chronic disease management?
Chronic disease management is the ongoing care of a health condition that has lasted, or is expected to last, six months or more. Rather than treating each problem as it comes up, your GP works with you on a plan for regular check-ups, monitoring, medicines and support, so your care stays organised and you know what to expect.
GP chronic condition management plans
A GP chronic condition management plan, often called a GP care plan, is a Medicare-supported plan your GP prepares with you. It replaced the older GP management plans and team care arrangements from 1 July 2025.
Who can have a GP care plan?
You may be eligible if you have at least one chronic or terminal medical condition, such as diabetes, heart disease, asthma, COPD, arthritis or chronic kidney disease. Your GP can confirm whether a plan is right for you.
What's included in a care plan?
Your plan will usually set out:
- Your health conditions and what matters most to you
- Your health goals
- The care, tests and check-ups you need
- Things you can do to look after your health
- Referrals to allied health professionals, where eligible
Allied health referrals
If you have a GP care plan, your GP may refer you to eligible allied health professionals, such as a dietitian, physiotherapist, podiatrist, exercise physiologist or diabetes educator. Medicare rebates are available for up to five individual allied health services each calendar year.
Reviewing your plan
Your GP will review your plan with you regularly to check how you're going and update your goals and care as your health changes.
How our practice nurses help
Our practice nurses work alongside your GP to support your care. They can help gather information for your plan, take measurements such as blood pressure and weight, and help keep your check-ups and reviews on track.
I already have an older GP management plan. Do I need a new one?
Plans made before 1 July 2025 remain valid for a transition period. When your plan is due for review, your GP can prepare a new GP chronic condition management plan for you.
Conditions we help manage
Diabetes management
Your GP can help you manage type 1 and type 2 diabetes with regular reviews of your blood sugar, blood pressure and cholesterol, and checks of your kidneys, eyes and feet. Your GP can adjust medicines where appropriate, refer you to a dietitian, diabetes educator or podiatrist, and help you register with the National Diabetes Services Scheme (NDSS).
Heart health and cardiovascular disease
Your GP can monitor and manage conditions such as high blood pressure, high cholesterol, heart disease and atrial fibrillation. Care may include regular checks, medicines, lifestyle advice and referral to a cardiologist when needed.
Asthma and COPD
Your GP can help you manage asthma and chronic obstructive pulmonary disease (COPD) with regular reviews, a written asthma or COPD action plan, checks of your inhaler technique and advice on avoiding triggers. Your GP can also check which vaccinations may be recommended for you.
Arthritis and autoimmune conditions
Your GP can help with osteoarthritis, rheumatoid arthritis, gout, lupus and other autoimmune conditions, including monitoring, managing pain and medicines, and coordinating care with a rheumatologist where needed.
Bone and joint health
Your GP can assess joint pain and back pain, check your risk of osteoporosis and arrange bone density testing where eligible. Your GP can also refer you to a physiotherapist, exercise physiologist or specialist to support your mobility and strength.
Weight management
Your GP can talk with you about your weight and how it relates to your overall health, check for related conditions such as high blood pressure and diabetes, and discuss options that may suit you, including nutrition, physical activity and referral to a dietitian or exercise physiologist.
Why your regular GP matters
Continuity of care is especially important when you have a long-term condition. If you are registered with MyMedicare, your GP care plan is prepared and reviewed through your MyMedicare registered practice. If Illawarra General Practice is your regular practice, our reception team can help you register.
Working with your specialists
Many people with chronic conditions also see a specialist. Your GP can refer you to the right specialist, share relevant information and coordinate your care between appointments, so you have one place to bring everything together.
Frequently asked questions
It's a Medicare-supported care plan your GP prepares for a long-term health condition. It sets out your goals and care, and can include referrals to eligible allied health services. It replaced GP management plans and team care arrangements from 1 July 2025.
Yes. GP care plans and reviews are bulk billed for patients with a valid Medicare card. Allied health providers set their own fees, and Medicare rebates may apply.
With a GP care plan, Medicare rebates are available for up to five individual allied health services each calendar year, if your GP refers you and you're eligible.
Book a longer appointment with your GP and let reception know it's for a care plan. Bring your medicines, recent test results and any specialist letters.
Plans made before 1 July 2025 remain valid for a transition period. When your plan is due for review, your GP will prepare a new GP chronic condition management plan.