Chronic Disease Management

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Chronic Disease  Management

Management of chronic and complex diseases

Staying Healthy

Staying healthy is important for all of us. However, it requires regular attention to reinforce our good behaviours and give us a nudge to focus on these rather than the enjoyable, but often, not so healthy ones. This can be hard if you are living with conditions of a chronic or ongoing nature, especially when several doctors or healthcare professionals are involved. Rest assured; we are here to help empower you to live a quality life with the effective chronic disease management Mt Gravatt has to offer.

Chronic conditions require regular, scheduled monitoring and progress checks to prevent poor long-term outcomes (just like servicing your car). Having an individualized, structured management plan that takes account of your condition, lifestyle and personal goals will allow you to live a long, normal, healthy life, doing what you love.

Keeping on top of risk factors like blood pressure, diabetes, cholesterol and asthma; reduces the long-term complications, allows you to feel better, and prolongs good health. Setting some goals and then making small changes more often makes it easier to get where you want to be. Identifying and managing barriers to healthy lifestyles, like the pain from arthritis, enables our patients to move closer to where they want to be.

At Reydon Street, we can help you choose your goals and monitor regularly to identify changes in the right or wrong direction early. We can also provide feedback about how you are doing and advise on changes to your approach with effective chronic disease management at our Mt. Gravatt clinic. All of this can optimise your health, sense of wellbeing and satisfaction with life.

This is where a GP Management Plan and Team Care Arrangement helps many of our patients.

Our approach  to chronic and complex conditions – Accessing GP Management Plans and Team Care Arrangements.

Patients with chronic or complex conditions usually benefit from a structured approach to their care. This often requires a multi-disciplinary team to deliver the necessary care. Our doctors and practice nurses work as a team with other health professionals to provide holistic care. Our practice nurse provides valuable assistance by helping with the ongoing monitoring and facilitating access to the allied health services in Mt Gravatt and neighbouring suburbs that patients need. Having a relationship with one practice means your records are all in one place and makes this easier for you to coordinate. We can also upload them to your My Health Record if you wish.


GP Management Plans (GPMP)

We frequently help our patients with chronic conditions develop a GP Management Plan (GPMP). This is  involves:

  • a  review of your medical conditions and medications
  • helping you identify barriers to optimising your health and  wellbeing
  • advising about recommended clinical goals and monitoring
  • developing a structured plan to help you navigate  your way through the healthcare system
  • using the lastest technology to help keep you on track with tests and review appointments
  • identifying if you are eligible for Medicare funded access to allied health services
  • developing a Team Care Arrangement and referring to  the other health providers
  • using our practice nurse to provide supportive, motivation and monitoring between visits to  your GP. (This is great if you need prompting to stay on track with a healthy habit you are trying to establish).

Team Care Arrangements (TCA)

These are for those patients who have complex care needs which require treatment from two or more health care providers in addition to your GP. These were formally call Enhanced Primary Care (EPC) services.

Having a TCA allows patients to access Medicare benefits for certain allied health providers – most typically:

  • dieticians
  • physiotherapists
  • podiatrists
  • exercise physiologists
  • psychologists
  • audiologists
  • diabetic educators

Our process is:

  • Book an initial appointment with the our nurse and another with your doctor Call our support team now on 07 3216 8500 .
  • We will send you a  list of your medical conditions and current  medications to check and update
  • Think about the current goals  you have to improve your sense of health and wellbeing
  • Send the information back to us before the appointment
  • Stay at home and make a cup of tea while you speak to the nurse (during CoVID-19 the will be by telephone)
  • Finalise  the  plan with you GP (this may be by telephone or in the clinic)

Visit the Department of Health’s information page for more detailed information.

If you would like a GP Management Plan (GPMP) and Team Care Arrangement (TCA) book an appointment at the practice. Please let the receptionist know you wish a GPMP and TCA at the time of  booking. This helps our practice nurse to start gathering the information for preparing the plan and to schedule the appropriate appointment length. Appointments for a new plan are billed direct to Medicare.


Ensure you or the person you care for is getting access to the correct level of funding to support their needs by requesting a MyAgedCare (ACAT) Assessment .

This is to access more help and support to keep  people safe and  function in their own  home or when the time is right to look into an aged care home.

See the types of care MyAgedCare can help you access. For example you can get some help with day-to-day tasks around the house, or respite care while your family or carer is away. Or perhaps it’s time to look into aged care homes. There are many services that can help you maintain a good quality of life as you get older.

You can apply on line here.

Local resources and assistance

Brisbane City Council Taxi Subsidy Scheme and Lift Payment

  • The Taxi Subsidy Scheme (TSS) subsidises taxi travel for people with severe disabilities. This may be approved for permanent or temporary disability.
  • The are  a number of eligibility criteria listed on the BCC website as well as links to the  application form.

Brisbane City Council Taxi Subsidy Scheme and Lift Payment

Apply for disability parking permit (Individual)

You may be able to get a disability parking permit  if your ability to walk is severely restricted by a medical condition or disability.You may be able to apply for an Australian permit if you are a Queensland resident and 1 of the following applies to you:

  • unable to walk and always require the use of a wheelchair
  • ability to walk is severely restricted by a permanent medical condition or ability to walk is severely restricted by a temporary medical condition or disability that you will have for 6 months or more as certified by your doctor or occupational therapist.

Apply for disability parking permit (Individual)

Community Flyer  bus

The TransitCare Community Fly buses  can meet the needs of eligible patients  who  have difficulty traveling to appointments because you can no longer drive or safely use public transport.  You must still be able to travel independently or with your carer and be happy to travel in shared transport with others.

See more about the eligibility criteria and costs on the TransitCare website


Reydon Street Medical Centre is moving on 14 February 2022

Reydon Street Medical Centre has a long history of providing high quality health care from trusted doctors from 2 Reydon Street on the corner of Newnham Road and Reydon Street in Upper Mt Gravatt.

The current health crisis means that it is no longer sustainable to continue this tradition from its original premises. To ensure we are more resilient and remain able to provide continuity of care to our patients in the face of sickness or furlough leave we need to be part of a larger organisation.

The great news is the legacy will continue and on 14 February 2022 Reydon Street Medical Centre will join the existing Holland Park General Practice at 1173 Logan Rd, Holland Park. This is part of the IPN Medical Centres network and is located just five minutes from our building.

We intend to provide the same high quality care from doctors you know and trust from more appropriate premises. You should also see the same friendly staff to look after you at the front desk.

Continuity of care and the security of our patient records is our priority. Patients records will be transferred automatically, so your doctor can continue to access them. Given the Holland Park General Practice is part of the IPN Medical Centres network, you can be assured that your health records and personal information will remain safe and secure.

We will continue to book appointments with your chosen doctor, but from Monday 14 February 2022 onwards, all existing and future appointments will take place at Holland Park General Practice.

We look forward to continuing to serve our patients from our new home.