Chronic Disease Management Program
Through the provision of ongoing monitoring, education and support PAMS aims to assist clients to live their best lives. Our primary health care focus is coupled with our comprehensive chronic disease management plans. This combined approach aims to prevent the development of chronic disease while screening for early warning signs.
Clients and families with chronic disease are reviewed regularly and supported to participate as fully as possible in their own self-management. Chronic disease medications are provided free of charge at all PAM’s clinics.
Chronic disease clients are also supported to travel to Perth, Newman and Port Hedland for specialist reviews. A number of visiting services including a renal physician and allied health teams, travel regularly to each of the PAMS communities to provide care to clients.
How to Access a GP Management Plan (GPMP)
If you have a chronic or ongoing medical condition that has lasted, or is expected to last, six months or more, you may be eligible for a GP Management Plan (GPMP).
Chronic conditions can include:
- diabetes
- heart disease
- arthritis
- asthma
- chronic pain
- mental health conditions
- other long-term health concerns that require ongoing care.
Am I eligible?
Eligibility is assessed by your GP during an appointment. Your doctor will consider:
- Whether you have a chronic or complex medical condition requiring ongoing management.
- Your current health needs and treatment goals.
- Whether a structured care plan would help coordinate your healthcare.
A GPMP is available to patients who meet the Medicare eligibility criteria.
What happens during a GPMP appointment?
Your GP will work with you to:
- Review your medical history, current medications, and overall health.
- Discuss your health goals and any challenges you are experiencing.
- Develop a personalised management plan outlining your treatment, self-management strategies, and ongoing care.
- Identify any additional support services that may benefit you.
Your appointment may take longer than a standard consultation to allow enough time to develop a comprehensive care plan.
Allied health referrals
If appropriate, your GP may recommend referrals to allied health professionals such as physiotherapists, dietitians, podiatrists, exercise physiologists, occupational therapists, or psychologists. Where eligible under Medicare, a GPMP may be combined with a Team Care Arrangement (TCA) to support access to Medicare rebates for selected allied health services. Your GP will discuss whether this is suitable for your individual needs and help coordinate your care.
Reviews and ongoing care-
Your GPMP should be reviewed regularly to ensure it continues to meet your healthcare needs. Reviews are commonly completed every 3–6 months, or sooner if your health changes significantly. During a review, your GP will assess your progress, update your goals, and make any necessary changes to your management plan.
Costs and Medicare
A GPMP is funded through Medicare for eligible patients. There is no out-of-pocket cost , fully medicare covered
Book an appointment-
To find out if you are eligible for a GP Management Plan, please contact or walk in to your local PAMS Clinic. Our team can guide you through the process, explain your options, and answer any questions you may have