Chronic Disease Management Plans: How to Get a GP Care Plan and What It Covers

If you’re living with a long-term condition like diabetes, asthma, heart disease, or arthritis, you may already be managing appointments with your GP, and sometimes a physiotherapist, dietitian, or other health professional too. A Chronic Disease Management (CDM) plan is designed to bring that care together, and at Supernova Medical Centre, it’s one of the most valuable — and most underused — services we offer.

What Is a Chronic Disease Management Plan?

A Chronic Disease Management plan, sometimes still referred to by its older name, a GP Management Plan (GPMP), is a structured plan your doctor creates with you to manage an ongoing health condition. It sets out your health goals, the treatment and services you need, and which providers will be involved in your care.

If needed, this can be paired with a Team Care Arrangement (TCA), which coordinates input from other health professionals, such as physiotherapists, podiatrists, dietitians, exercise physiologists, or diabetic educators.

The plan isn’t just paperwork. It’s a practical tool that helps you and your GP track progress, stay on top of referrals, and make sure nothing falls through the cracks between appointments.

Who Is Eligible?

You may be eligible for a CDM plan if you have a chronic medical condition that has lasted, or is expected to last, six months or longer. This covers a broad range of conditions, including but not limited to:

• Diabetes (type 1 or type 2)
• Asthma or chronic respiratory conditions
• Cardiovascular disease
• Arthritis and musculoskeletal conditions
• Chronic pain
• Mental health conditions, when combined with a physical chronic condition
• Obesity-related health risks

If you’re unsure whether your condition qualifies, this is best discussed directly with your GP, who can assess your situation and determine the most appropriate plan.

What’s Included in the Plan

When your GP prepares a CDM plan, it typically includes:

1. An assessment of your current health needs — a review of your condition, history, and any complications
2. Clear, measurable goals — for example, improved blood sugar control, reduced pain levels, or better mobility
3. A list of required treatments and services — medications, allied health referrals, or further tests
4. A referral pathway — access to Medicare-subsidised allied health visits, often up to five per calendar year under a TCA
5. A review schedule — regular check-ins to track how you’re progressing against your goals

At Supernova, our allied health team, including physiotherapists, podiatrists, exercise physiologists, dietitians, and diabetic educators, work directly within this framework, so referrals are coordinated in-house rather than sending you elsewhere.

Why This Matters for Long-Term Health

Chronic conditions are rarely managed well through occasional, reactive visits alone. A CDM plan shifts the approach from “treat it when it flares up” to structured, ongoing management, which has been shown to improve outcomes for conditions like diabetes and cardiovascular disease over time.

For patients managing diabetes specifically, this often means regular contact with our diabetic educator, alongside GP oversight of medication and bloodwork, all under one coordinated plan rather than separate, disconnected appointments.

How the Subsidised Allied Health Visits Work

One of the most valuable parts of a Team Care Arrangement is access to Medicare-subsidised allied health sessions. Depending on your plan, you may be eligible for up to five allied health visits per calendar year, shared across the relevant services your GP has referred you to.

At Supernova, this could include:

• Physiotherapy for mobility or musculoskeletal conditions
• Podiatry for diabetes-related foot care
• Exercise physiology for structured, condition-specific fitness programs
• Dietitian consultations for nutrition-related management
• Diabetic education for day-to-day condition management

Because these services are available in-house, your GP can coordinate your plan and referrals without you needing to seek out separate providers.

How to Get Started

Setting up a CDM plan is simple:

1. Book a standard appointment with your regular GP at Supernova
2. Discuss your condition and whether a management plan is appropriate for you
3. Your GP will prepare the plan, which may take a slightly longer consultation to complete properly
4. Referrals are arranged for any allied health services included in your Team Care Arrangement
5. Review appointments are scheduled periodically to check your progress and adjust the plan if needed

Because Supernova bulk bills these consultations, there’s no financial barrier to setting one up or attending your review appointments.

The Bottom Line

If you’re managing a chronic condition and currently juggling separate appointments without a clear plan tying them together, a Chronic Disease Management plan could make a real difference to how effectively that condition is managed over time. It’s a service many patients don’t realise they’re eligible for.

To find out whether a CDM plan is right for you, book an appointment with your GP at Supernova Medical Centre by calling 03 8866 5544 or booking online. It’s a conversation worth having, especially if you’ve been managing your condition on your own for a while.