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Services > Chronic Disease Management

There are a number of well defined conditions which require many different contributions from across the spectrum of medical care.

Your GP is best positioned to consider which areas of allied health would be most useful to achieve the best care possible.

A CDM Plan is a process whereby your GP has time to consider your needs in detail. The Care Planning process usually occurs every 1-2 years and is reviewed at least every 6 months.

A chronic medical condition is one that has been (or is likely to be) present for six months or longer, for example, asthma, cancer, cardiovascular disease, diabetes, chronic musculoskeletal conditions,(e.g. Osteoporosis and advanced Arthritis) and stroke. There is no formal list of eligible conditions. However, the CDM items are designed for patients who require a structured approach and to enable GPs to plan and coordinate the care of patients with complex conditions requiring ongoing care from a multidisciplinary team.

Patients have complex care needs if they require ongoing care from a multidisciplinary team consisting of their GP and at least two other health care providers.

The need for allied health services must be directly related to a patient’s chronic condition and identified in their care plan. GPs determine whether the patient’s chronic medical condition would benefit from allied health services.

Dr Hearnden was fortunate to be one of the directors of the original TeamCare trial held in Brisbane North. Much of the design of the care planning process was determined by the GP’s and staff of Brisbane North Division of General Practice (now the Brisbane North Public Health Network (PHN)).

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