Chronic Condition Management
At Meroo Street Family Practice, we provide chronic disease management in Bomaderry and Nowra for patients living with long-term health conditions that need regular care and follow-up. Our GPs can help with Chronic Condition Management Plans, ongoing reviews, medicine monitoring, allied health referrals, and practical support to help you manage your health over time. Whether you have recently been diagnosed or have been living with a condition for years, our team is here to help you stay on top of your care with a clear and coordinated plan. A local provider of ongoing care for patients managing long-term health challenges.
What Chronic Condition Management Includes
Chronic condition management is GP support for health conditions that last 6 months or more. This may include a personalised plan, regular reviews, and referrals to allied health providers where needed.
At our clinic, chronic disease management may involve:
- reviewing your medical history and current medicines
- setting health goals with your GP
- preparing a GP Chronic Condition Management Plan
- arranging referrals to allied health or other care providers
- booking follow-up reviews to monitor how you are going over time.
This approach is designed to make long-term health care more organised, more practical, and easier to manage.
Conditions We Commonly Help Manage
Meroo Street Family Practice commonly helps manage a broad range of long-term health concerns, including:
- Arthritis
- Asthma
- Diabetes
- Emphysema
- Heart disease
- High blood pressure
- Kidney disease
- Osteoporosis
- Sleep apnoea
- Cancer
- Depression and anxiety
If you are living with one or more chronic conditions, regular GP care can help with monitoring, treatment planning, referrals, and support for day-to-day management.
GP Care Plans, Reviews, And Allied Health Referrals
One of the main services offered through chronic condition management is a GP Chronic Condition Management Plan (GPCCMP). It documents your health goals, medicines, and care team, and helps coordinate support from your GP and other providers such as a dietitian or physiotherapist.
For many eligible patients, a care plan may also open access to up to 5 individual Medicare-rebated allied health services per calendar year, depending on clinical need and referral requirements. This also notes that reviews are typically completed every 3 months if clinically needed, and that plans should be prepared or reviewed within the last 18 months to maintain Medicare access to allied health services.
Personalised Support For Long-Term Health
No two patients manage chronic illness in exactly the same way. Some people may need support with lifestyle changes, monitoring, and routine reviews. Others may need help coordinating care across multiple conditions, medicines, allied health providers, and specialists.
The current services already highlights:
- personalised care planning
- ongoing medical support
- emotional and lifestyle support.
We can use that approach to support your goals in a practical way, whether that means reviewing progress, adjusting care over time, or helping you feel more confident about managing your health day to day.
What To Bring To Your Care Plan Appointment
To help your GP prepare or review your plan efficiently, recommends bringing:
- your Medicare card
- a current medication list
- any recent test results
- any letters from specialists or allied health providers.
Having these details available can make it easier to coordinate your care and organise referrals where needed.
How Often Care Plans Are Reviewed
The care plan reviews are typically completed every 3 months if clinically needed. It also explains that care plans do not technically expire, but they should be prepared or reviewed within the last 18 months if you want to keep accessing eligible allied health services through Medicare.
Regular reviews can help your GP:
- check how your treatment is going
- monitor medicines and symptoms
- update referrals
- review your health goals
- adjust your management plan over time
Mental Health And Chronic Condition Support
Living with a long-term condition can affect more than just physical health. It can also impact your emotional wellbeing, especially when you are managing symptoms, appointments, medicines, and day-to-day changes over time. Support for depression and anxiety may be available through a Mental Health Treatment Plan, which is separate from the allied health visits available under chronic disease management.
If mental health is affecting how you manage your physical health, your GP can discuss suitable support pathways and referral options during your appointment.
Local Chronic Disease Management For Bomaderry, Nowra, And Nearby Areas
Meroo Street Family Practice is based in Bomaderry NSW and supports patients from Bomaderry, Nowra, and nearby Shoalhaven communities who are looking for local, ongoing GP care for long-term health conditions. The clinic is also convenient for patients travelling from surrounding areas such as Berry, Kiama, Tomerong, Worrigee, Cambewarra, Gerringong, Callala Bay, Coolangatta, North Nowra, Callala Beach, Culburra Beach, and Shoalhaven Heads.
Related Services You May Also Need
Depending on your health needs, you may also want to explore related services on the site, including:
- Family Healthcare
- Essential Medical Checkups
- Targeted Health Assessments
- Health Checks & Expert Advice
- Doctors in Nowra
- Bomaderry Doctors
Book A Chronic Disease Management Appointment
If you are looking for chronic disease management in Bomaderry or Nowra, Meroo Street Family Practice can help with GP care plans, reviews, allied health referrals, and ongoing support for long-term conditions.
Book online or call our clinic on (02) 4421 4655 to arrange an appointment. The clinic at 1 Meroo St, Bomaderry NSW 2541, with opening hours Monday to Friday, 8:00am to 6:00pm.
Frequently Asked Quesitons
What is “Chronic Condition Management Plan”?
It’s coordinated, long-term GP care to help you live well with conditions that last 6 months or more (e.g., diabetes, heart or lung disease, arthritis). It can include a personalised plan, reviews, and referrals to allied health.
What is a GP Chronic Condition Management Plan (GPCCMP)? Is it the same as a care plan?
Yes—this is the current Medicare term (replacing the old GPMP/TCA language). Your GP documents your health goals, medicines, and team (e.g., dietitian, physio) and coordinates your care.
Am I eligible for a plan?
Generally, yes if you have a chronic or terminal condition present (or likely) for ≥ 6 months. To access allied health under Medicare, you also need complex care needs (your GP plus at least two other health providers involved).
How many Medicare-rebated allied health visits can I get each year?
Most eligible patients can access up to 5 individual allied health services per calendar year (any mix—e.g., 3 physio + 2 dietetics) when recommended in your plan and referred by your GP. Mental health sessions sit under a separate program.
How often are plans reviewed—and do they expire?
Reviews are typically every 3 months if clinically needed. Plans don’t “expire”, but to keep accessing allied health through Medicare your plan should be prepared or reviewed within the last 18 months.
Are care plans and reviews bulk billed at your clinic?
Yes. At Meroo Street Family Practice, Care Plans (once a year) and Care Plan Reviews (up to 3 times a year) are bulk billed for all patients. (Other consult fees may apply separately.)
How do I book a care plan appointment?
Book online or call reception. We’re open Monday–Friday, 8:00 am–6:00 pm.
What should I bring to my care plan appointment?
Bring your Medicare card, current medication list, recent test results, and any letters from specialists or allied health—this helps your GP coordinate your plan and referrals efficiently.
Does this include mental health support?
Mental health care is available via a Mental Health Treatment Plan with Medicare rebates for up to 10 individual sessions per calendar year with eligible providers—separate from the 5 allied-health CDM visits.
Are there extra supports for Aboriginal and Torres Strait Islander patients?
Yes. After a health assessment, additional allied health services may be available under specific Medicare items—your GP will explain what you’re eligible for and arrange referrals.