Chronic diseases are broadly defined as medical conditions that last one or more years, and which need ongoing medical care, or which modify activities of daily living, or both.
What is Team Care Arrangement EPC referral?
If you have a chronic medical condition and complex care needs requiring multidisciplinary care, your GP may develop Team Care Arrangements (TCAs) under the Enhanced Primary Care (EPC) referral system. These will help coordinate the care you need from your GP and other health professionals or care providers.
Under a TCA, your GP will collaborate with at least two other health professionals or care providers that will give ongoing treatment or services to you. Please let your GP or nurse know if there are aspects of your care that you do not want discussed with other health care providers.
What is a GP Management Plan?
A GP Management Plan (GPMP) can help people with chronic medical conditions by providing an organised approach to care. A GPMP is a plan of action you have agreed with your GP. This plan identifies your health and care needs and sets out the services to be provided by your GP. It also lists the actions you can take to help manage your condition.
If you have a medical condition that has lasted or could last for more than six months, you might be eligible for a chronic disease management plan and a team care arrangement.
Some examples of chronic diseases are:
- Diabetes mellitus
- Asthma
- High blood pressure
- Hyperlipidaemia
- Obesity
- Dementia
- Emphysema/COPD
- Ischaemic heart diseases
- Osteoarthritis
- Chronic pain syndromes
- Chronic kidney diseases
- Congestive heart failure
Diabetes Mellitus
Diabetes is a chronic, metabolic disease characterised by elevated levels of blood glucose (or blood sugar), which leads over time to serious damage to the heart, blood vessels, eyes, kidneys and nerves.
Your blood sugar is controlled by a hormone called insulin, which converts sugar/ glucose into energy. Diabetes occurs when your pancreas can’t produce adequate insulin or when your body develops a resistance to insulin.
Types of diabetes
- Type 1 diabetes – a person’s own immune system breaks down the cells in the pancreas that produce insulin.
- Type 2 diabetes – the body’s cells do not respond effectively to insulin, or the body loses the ability to produce enough insulin in the pancreas.
- Gestational diabetes occurs when a woman experiences high blood glucose levels during pregnancy. It usually goes away after the baby is born. Women who experience gestational diabetes have a higher risk of developing type 2 diabetes in the future.
- Pre-diabetes – when blood glucose levels are higher than usual, but not high enough for a diagnosis of diabetes.
Risk factors for diabetes include:
- a family history of diabetes
- low levels of physical activity
- poor diet
- being obese or overweight
If your doctor suspects you have diabetes, you will be asked to have a blood test to check glucose levels. After diagnosis, your doctor will discuss a treatment plan which may involve lifestyle modifications and/or medications. You will also be eligible to have a Diabetes Care Plan and EPC referral for a team care arrangement to manage your diabetes effectively.
Diabetes can have a big impact on your mental health — more than 3 in 10 people with diabetes experience depression, anxiety, and distress.
Talk to your doctor or a diabetes educator about how to look after yourself to minimise — or even prevent — diabetes and diabetes related complications.
Obesity
Obesity can be a sensitive topic. It’s important to remember that obesity is not just about how you look — it increases your health risks (heart disease, type 2 diabetes and other serious medical conditions).
Weight that is higher than what is considered healthy for a given height is described as overweight or obese. The Body Mass Index (BMI) is a screening tool to help determine if patients are overweight or obese.
- BMI 18.5 to <25- healthy weight range.
- BMI 25.0 to <30- overweight range.
- BMI 30.0 or higher- obesity range.
If you are concerned about your weight, don’t hesitate to talk to our friendly GPs about your concerns. Our doctors understand the sensitive nature of your condition and they will support you with no judgement. There is no quick fix for obesity, but your doctor can support your through your journey.
Obesity management includes:
- Healthy, balanced, low-calorie diet
- Physical activity
- Support team for weight loss – your GP can provide a GPMP and team care referral including a dietician, exercise physiologist, psychologist or any other appropriate allied health service provider.
- Weight loss medications
- Weight loss surgery – if appropriate, your GP may provide a referral to a bariatric surgeon.
Osteoarthritis
Osteoarthritis is a chronic medical condition in which your joints become inflamed and damaged. Over time, the cartilage layer that protects the ends of your bones wears away, and new spikes of bone may develop. Without cartilage, the bones in the joint rub together, causing pain, swelling, stiffness and reduced movement. This could reduce your functional capacity – exercise, walking, climbing stairs and other daily activities.
Osteoarthritis becomes more common as you get older. It affects 1 in 5 Australians over age 45 and 1 in 3 over age 75. It is more common in females than males.
Risk factors for osteoarthritis include:
- overweight/obesity
- previous injury to a joint, such as a dislocation or a fracture
- family history of osteoarthritis
- occupations that involve repetitive movements (such as kneeling, climbing, squatting, heavy lifting, or hand movements)
Osteoarthritis management includes:
- Physiotherapy/hydrotherapy and regular exercise
- Healthy eating and maintaining a healthy weight
- Joint injections
- Pain management / pain relievers
You could be eligible to access services with a GPMP + EPC referral.