If you live with a long-term condition such as diabetes, heart disease, asthma, COPD, arthritis or chronic kidney disease, regular structured care from a GP who knows you makes a measurable difference. At Red Hill Family Clinic your GP can set up a care plan, coordinate the other health professionals involved, and review you at set intervals so problems are caught early. Dr Massoudi and Dr Pavasaris both have a particular interest in chronic disease management.

Book a care plan appointment Call (03) 5985 6662

GP Chronic Condition Management Plans

A GP Chronic Condition Management Plan is a written plan your GP prepares with you that sets out your condition, your goals, the actions you and your GP will take, and the other health professionals involved, such as a podiatrist, dietitian, physiotherapist or diabetes educator. With a plan in place, Medicare contributes to up to five allied health visits each calendar year. Since 1 July 2025 this single plan has replaced the older GP Management Plan and Team Care Arrangement; if you had one of those, your GP will move you across at your next review. Plans are reviewed regularly with your GP, and Medicare supports a review every three months.

Health checks

Heart health check

For anyone aged 45 and over (30 and over for Aboriginal and Torres Strait Islander patients), a heart health check assesses your blood pressure, cholesterol, blood sugar, weight, smoking and family history to estimate your risk of a heart attack or stroke in the next five years, and gives you a plan to lower it. Where needed, we fit a 24-hour blood pressure monitor.

45 to 49 year old health check

If you are aged 45 to 49 and have a risk factor for a chronic condition, such as a family history, being overweight, smoking or high blood pressure, this Medicare-funded check identifies problems early, while they are easiest to change.

75 and over health assessment

An annual assessment for people aged 75 and over that looks at physical health, mobility and falls risk, memory and mood, hearing and vision, medicines, nutrition, and how you are managing at home, which matters particularly for patients living on larger properties in Main Ridge, Red Hill and Shoreham. If you take several medicines, your GP may also arrange a Home Medicines Review.

Aboriginal and Torres Strait Islander health check

A health check every nine months for Aboriginal and Torres Strait Islander patients of any age, covering physical, social and emotional wellbeing, with access to follow-up allied health services under Medicare.

Diabetes annual cycle of care

A structured yearly review for people with diabetes covering blood sugar control, kidney function, eyes, feet, blood pressure, cholesterol and weight, with referrals to a diabetes educator, podiatrist or dietitian under your care plan.

Fees

Care plans, reviews and the health checks above are Medicare items. For eligible patients they are bulk billed across all our consulting hours; otherwise a private fee applies and Medicare pays a rebate. Please book a long appointment and tell reception which check or plan it is for.

Common questions

What is a chronic disease management plan?

A Medicare-funded plan your GP writes with you for a condition that has lasted, or is likely to last, six months or more. It sets goals, lists the care you need and the health professionals involved, and unlocks Medicare support for up to five allied health visits a year.

Who is eligible for a GP Chronic Condition Management Plan?

Anyone with a chronic or terminal medical condition. Your GP decides whether a plan would help you.

How many allied health visits does a care plan cover?

Up to five Medicare-rebated visits per calendar year, shared across the allied health providers named in your plan.

How often is my plan reviewed?

Regularly, usually every three to six months depending on your condition, or sooner if something changes. Medicare supports a review every three months.