If you live with a long-term condition, the post-holiday reset is a great moment to organise your care. Routines are returning, kids are back at school, and you can finally book the appointments that slipped in December.
At The Pines Medical Practice in Elanora, our GPs and practice nurses help you build a practical plan to manage your health over the year ahead. A GP Management Plan and Team Care Arrangement can connect you with allied health, reduce out-of-pocket costs, and give you a clear roadmap to follow between visits.
This guide explains what chronic disease care plans are, who is eligible, how Medicare rebates work, and what to expect at your appointment. It also includes tips to help you make the most of each visit.
What is a chronic care management program?
In Australian general practice, “chronic disease management” usually refers to two linked documents prepared by your GP for conditions that have lasted, or are expected to last, more than six months:
- GP Management Plan (GPMP): Your personalised summary of diagnoses, medications, risk factors and day-to-day goals.
- Team Care Arrangement (TCA): A coordination plan that involves your GP and at least two other health professionals, such as a physiotherapist and a dietitian.
Together, these plans support ongoing care for conditions like type 2 diabetes, heart disease, asthma, chronic obstructive pulmonary disease, osteoarthritis, persistent musculoskeletal pain and more.
At The Pines, care planning is nurse-led with GP oversight. Our practice nurse completes a structured assessment, then your GP reviews, finalises and shares the plan with you.
Who is eligible?
You may be eligible for a GPMP if you have a chronic or terminal condition that has been present, or is likely to be present, for at least six months. Common examples include:
- Type 2 diabetes or pre-diabetes risk factors
- Coronary artery disease, hypertension or high cholesterol
- Asthma or chronic obstructive pulmonary disease
- Osteoarthritis, chronic back or neck pain, and other persistent musculoskeletal problems
- Chronic kidney disease, autoimmune disorders and some mental health conditions
A TCA is added when your GP coordinates your care with at least two other providers. Your GP will confirm eligibility during your appointment.
What happens in a care planning meeting?
Your care planning visit at The Pines typically involves:
- Nurse-led assessment. We record vitals, review current medications and supplements, check allergies, and gather recent test results and referrals. We ask about symptoms, pain, sleep, mood, diet and activity.
- Goal setting and action steps. Together we set 1 to 3 realistic goals with timelines, for example walking 20 minutes five days a week, reducing sugary drinks, or using a spacer with your inhaler.
- Allied health referrals. If needed, your GP prepares referrals for services like physiotherapy, exercise physiology, podiatry, diabetes education or dietetics.
- A written plan. You receive an accessible summary with your targets, due dates for reviews, and who to contact if symptoms change.
Expect to spend longer than a standard visit. Bring your Medicare card and any concession cards so rebates can be processed at the time of payment.
How Medicare-subsidised allied health visits work
When you have a current GPMP and TCA, you may access Medicare-subsidised allied health sessions. Most people receive up to five subsidised visits per calendar year in total, shared across eligible providers. Your GP will help you prioritise which services are likely to make the biggest difference first.
Allied health clinics set their own fees. Medicare pays a fixed rebate toward each visit, and a gap fee may apply. Always ask the allied health provider about costs before booking.
How many sessions do you get?
With a valid GPMP and TCA, Medicare typically contributes to up to five allied health sessions per calendar year. These can be split across providers, for example three physiotherapy and two dietetics. Your GP can reallocate sessions within the year if your needs change.
People with complex diabetes needs may also be eligible for separate Medicare-subsidised podiatry or diabetes education under organised diabetes care. Your doctor will advise if this applies to you.
What the plan includes at The Pines
Our integrated model pairs nursing expertise with GP continuity:
- Nurse-led assessment and education at the first visit
- GP review to finalise diagnoses, medications and referrals
- Clear goals across lifestyle, medications and monitoring
- Six-monthly reviews to track progress, update goals and refresh referrals
- Reminders for key checks, such as blood tests, blood pressure, asthma inhaler technique or foot checks in diabetes
We also offer type 2 diabetes risk assessments to help you understand your baseline and set targeted prevention or management steps. If that is front of mind, read more about our diabetes risk assessments in Elanora and the wider Gold Coast area on our website.
Examples of useful goals
Good goals are specific, achievable and measurable. Patients often choose:
- Exercise: 150 minutes of moderate activity per week, two strength sessions, or a daily 20-minute walk.
- Nutrition: Adding two cups of vegetables daily, swapping sugary drinks for water, or seeing a dietitian to tailor carbohydrate portions.
- Medications: Using a weekly pillbox, updating a medication list, or setting alarms for inhalers.
- Monitoring: Checking blood pressure at home twice weekly, or bringing glucose readings to each review.
- Symptom management: Physiotherapist-guided strength plan for knee pain, or a respiratory action plan for flare-ups.
How often plans and reviews occur
Most GPMPs are reviewed every six months to keep your goals and referrals current. If your health changes sooner, we can review earlier. Annual updates ensure your plan stays active and relevant, and that you continue to qualify for subsidised allied health where appropriate.
Costs and rebates at The Pines Medical Practice
The Pines Medical Practice is a mixed-billing clinic. Each doctor sets their own fees, and Medicare rebates are processed at payment via integrated EFTPOS. Typical published fees are:
- Standard consultation: $90.00
- Long consultation: $130.00
Concession and child pricing is available as per our fee policy, and aged pensioners may be bulk-billed for eligible GP consultations. Gap fees may apply to care planning appointments and to allied health visits, depending on provider policies. For the most current fees, please speak with reception before your appointment so there are no surprises.
If you are ready to get organised, you can book online with our Elanora medical centre. Same-day options are often available for urgent needs.
Tips to bring to your care planning appointment
- A list of all medications and supplements, with doses
- Results or letters from hospitals and specialists
- Home readings, such as blood pressure or glucose logs
- Your goals and questions, written down
- Comfortable clothing for measurements and examinations
How effective is chronic care management?
Care planning is not a quick fix, but evidence shows that structured follow-up, clear goals and coordinated allied health can improve control of conditions like diabetes and hypertension, reduce flare-ups in asthma, and support safer medication use. The biggest gains come when plans are realistic and reviewed regularly, and when you feel confident to take small steps between visits. Our team focuses on practical education and achievable targets so you can build momentum.
FAQ
- Who is eligible for a chronic condition management plan?
Adults and children with a condition lasting, or expected to last, at least six months. Your GP confirms eligibility.
- How many sessions do you get with a plan?
Usually up to five Medicare-subsidised allied health visits per calendar year, shared across providers.
- What is a chronic care management program?
At The Pines it is a GPMP plus a TCA, developed by your GP and practice nurse, with coordinated goals and referrals.
- How effective is chronic care management?
It often improves day-to-day control, supports healthier habits and reduces complications when plans are followed and reviewed.
- What happens in a care planning meeting?
A nurse-led assessment, GP review, goal setting, and allied health referrals, with a written plan you can use at home.
Ready to start?
A fresh term is an ideal time to reset your health. Book a chronic care management plan in Elanora at The Pines Medical Practice and bring your medication list and any recent results. If diabetes is your focus, you can also explore our type 2 diabetes reviews in Elanora to set a strong foundation for the year.
Helpful links on our site:
- Learn about chronic disease management plans in Gold Coast on our Chronic Disease page.
- Read about diabetes risk assessments in Gold Coast to understand your baseline and next steps.
- Book a GP appointment online when you are ready.
If you have questions or need help gathering paperwork, our friendly reception team is here to help during business hours.
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