Chronic Disease

Many people have ongoing health problems and these are called “Chronic Diseases”. 

This includes Diabetes, heart disease, arthritis and many other conditions. There are a number of services funded under Medicare that are designed to help you to manage your chronic disease/s so that you remain as well as possible for as long as possible. These services are usually bulk billed so you do not have to pay any out of pocket costs. At Mount Martha Village Clinic we have a major emphasis on preventative medicine.

Our aims are:

  •  To identify those people who may be at higher risk of chronic (long term) illness to assist in bringing about the changes that will reduce this risk to prevent or delay the onset of long term illnesses.
  • To monitor and treat any chronic illness optimally to prevent complications. The most common “Chronic diseases” currently include diabetes, heart disease, cancers and osteoporosis.

The federal government acknowledges the benefit of preventative medicine and assists by funding certain programs to make this affordable for everyone: GPMP: General Practice Management Plans TCA: Team Care Arrangement referrals.

GPMP: General Practice Management Plans


Anyone who has already been diagnosed with a condition such as diabetes is eligible for a GPMP. This includes education, setting goals, and making sure the condition is optimally treated to reduce the risk of complications and stay well. This consultation takes 60-90 minutes (partly with one of our nurses and partly with your usual doctor) and is fully covered by Medicare. For further information about Management Plans – what conditions are eligible and what is involved – visit the following site:

GP Management Plan Review.


We encourage you to attend a shorter appointment every 6 months to review your management plan. Once again you meet with a practice nurse followed by your GP.

TCA: Team Care Arrangements


If you have a condition suitable for a GPMP you are also eligible for a TCA provided you have at least two other health care providers (eg. physio, a specialist) caring for you as part of your “team”. This is so that all your care providers are working together to achieve the best outcomes for you. This requires written consent from your health care providers and this can take a little organising.  If you have a TCA, Medicare will also partly subsidise 5 visits each year to the Allied health care providers of your team.

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