This is a comprehensive document that sets out and enables evidence-based management of your chronic health and care needs. A chronic condition is deemed to be one that you have, or will have, for more than 6 months. This plan is done once every two years, with regular reviews of your progress against the plan, and it is direct billed to Medicare. The most common chronic diseases are: diabetes, asthma, emphysema, coronary heart disease, cancer of any type, osteoporosis and arthritis.
The plan involves you meeting with the practice nurse first, for about 30 mins, to discuss your medical condition/s and work with you to set goals and tasks to meet these goals. You will then see the doctor to complete the plan and look at what you have identified as to medical problems and goals. You will receive a copy of this plan for your records. The doctor will want to see you in 6 months time to review the goals and tasks and discuss any issues you have about the plan.