Chronic Disease Management

Ongoing, planned care for long-term conditions such as diabetes, asthma, COPD and heart failure, with care plans and access to allied health.

Living with a long-term health condition is easier with a plan. At Mediclinic, our GPs can prepare a chronic disease management plan in Clayton South to help you manage your condition, set goals and connect with other health professionals. We focus on keeping you well and helping you avoid unnecessary hospital visits.

A long-term (chronic) condition is one that lasts six months or more, such as diabetes, asthma or heart disease.

Conditions we help manage

Our GPs and Nurse Practitioners provide ongoing care for many conditions, including:

  • type 1 and type 2 diabetes
  • asthma and COPD
  • heart failure and other heart conditions
  • high blood pressure and high cholesterol
  • arthritis and chronic pain
  • kidney disease
  • mental health conditions, alongside our mental health services
  • lifestyle-related conditions, including healthy weight management

Dr Xue-Feng Hu has a special interest in chronic health management and preventative health. Nurse Practitioner Vara Perikala has a background in respiratory, general medicine and coronary care. She has a focus on preventing hospital admissions for people with asthma, COPD and heart failure.

What is a chronic disease management plan in Clayton?

Medicare supports GP care plans for people with chronic conditions. A care plan is a written plan that you and your GP prepare together. It usually sets out:

  • your health needs and goals
  • the treatments and services you need
  • the actions you can take to manage your condition
  • when your care will be reviewed

If your care involves other health professionals, your GP can coordinate a team approach. This is sometimes called team care arrangements. Medicare rules for care plans and the names used for them can change, and your GP will explain the current options.

Book a long appointment

Tell reception you would like a care plan so enough time is booked. Bring your medicines list and any recent test results.

Assessment and goals

Your GP reviews your health and talks with you about your goals and what matters to you.

Your written plan

Together you agree on a plan, including any referrals to allied health or other services.

Regular reviews

We review your plan at regular intervals and update it as your needs change.

Allied health under one roof

With an eligible care plan and referral, you may be able to access some Medicare-rebated allied health sessions each calendar year. Several allied health providers work from our Clayton South clinic:

Podiatry

Foot and nail care, diabetic foot care and more. Bulk billing for podiatry is available if you have a chronic disease management plan from your Mediclinic GP. See podiatry.

Dietitian

Support with healthy eating, diabetes, cholesterol and weight. See dietitian.

Physiotherapy

Exercise and movement support for chronic pain, injury and mobility. See physiotherapy.

Pathology collection by Australian Clinical Labs is also onsite, so routine blood tests can often be done on the same day as your appointment. See pathology.

Fees

Mediclinic is a mixed-billing practice. Bulk billing may be offered at the practitioner’s discretion for some eligible patients, including care plans. Allied health fees vary by provider. Fees may change, so see /fees/ or ask reception.

Who is eligible for a care plan?

Care plans are for people with a chronic or long-term condition. Your GP will assess whether you are eligible and which type of plan suits your needs.

Is a care plan bulk billed?

Care plans are one of the categories some of our practitioners may bulk bill, at their discretion. Please check with reception before your appointment.

How many allied health sessions can I get?

With an eligible plan and referral, Medicare provides a rebate for a set number of allied health sessions each calendar year. Your GP will explain the current rules. Some providers charge a gap fee.

How often should my plan be reviewed?

Your GP will let you know. Regular reviews help keep your plan up to date as your health changes.

Can my family or carer come to my appointment?

Yes. We are a family-inclusive practice and welcome carers and family members who help with your care.

Book an appointment

By appointment only. Book online any time or call reception. New patients welcome.


Monday – Friday
9am – 6pm
Saturday – Sunday
Closed

By appointment only — no walk-ins. Closed public holidays.

Address

Factory 25, 14–26 Audsley Street
Clayton South VIC 3169
Get directions

Phone

(03) 9544 1555
Fax (03) 9544 8137