A Guide to Care Plans for People with Chronic Medical Conditions
(GP Management Plans)
What are care plans?
Care plans are comprehensive plans for the care of patients with chronic conditions who need care from their doctor and at least two other health workers or care providers. Care plans provide the opportunity for all the providers involved in caring for you to plan your care in a coordinated fashion in consultation with you.
Who would benefit from a care plan?
Anyone who has a condition that lasts longer than six months (for example, diabetes, arthritis, intellectual disability or asthma), and needs the care of their GP and at least two other health workers or care providers (for example a physiotherapist, medical specialist, community nurse or other community care provider). People who require palliative care services, and people with chronic problems being discharged from hospital, may also benefit. There are no age restrictions. Even young children or teenagers can benefit from their GP planning care with other providers.
Who prepares the plan?
Generally, you will have an appointment with the nurse then the doctor to prepare the plan with your assistance. A care plan is an important part of your care, so it is advisable that your usual doctor or usual practice is the one preparing the plan. Together you will decide:
- What your health care problems and needs are;
- What result you would like from the care plan; and
- What other health care and community services you need.
Your doctor must obtain your consent before developing a care plan. You can also tell your doctor about any aspects of your assessment you do NOT want discussed with the other providers.
When is a care plan done?
Care plans may be prepared every twelve months, and should be reviewed after three months or when needed. Significant changes to your health may indicate the need for a new plan (for example, discharge from hospital)
Are there any costs?
Medicare pays a rebate for care planning.
(information sourced from RACGP)