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 some of the enjoyable but often not so healthy ones.

Keeping on top of blood pressure, diabetes, heart disease risk factors and asthma reduces the long-term complications and prolongs good health. Setting some goals and then making small changes more often makes it easier to get where you want to be. We can help you choose your goals, monitor regularly  to identify changes in the right or wrong direction early and provide feedback about how you are doing and advise on changes to our approach. All of this can optimize your health outcomes.

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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 nurse 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 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.

Patients with a chronic condition may benefit from a GP Management Plan (GPMP). Team Care Arrangements (TCA) 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

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