Chronic Disease Management (CDM) Team

Chronic disease – it’s on the rise

Compared to previous generations, Australians on average are living longer lives. This is primarily due to general improvements in our standard of living and recent advances in medical technology and treatment.

CDM Team

However, increased longevity has led to significant increases in chronic disease rates, with recent reports stating that up to 50% of Australians suffer from at least one chronic disease – and this figure is expected to rise in the future!

Importantly, poorly managed or supported chronic disease is likely to have detrimental effects on an individual’s (and their support network’s) physical, emotional and economic health and wellbeing.

Early detection can make a difference

The good news is, that early detection and effective treatment, management and support of a chronic disease may:

  • prevent the onset (it is estimated that up to one-third of chronic disease cases are preventable)
  • lessen the severity
  • delay the progression/minimise complications
  • improve quality of life

How do I know if I have a chronic disease?

Put simply, chronic disease refers to any long-lasting condition (of at least 3-6 months duration) with persistent effects.
Examples of the most common forms of chronic disease include:
  • arthritis
  • asthma
  • back pain
  • cancer
  • cardiovascular disease (e.g. coronary heart disease/ stroke – heart health)
  • chronic kidney disease
  • chronic obstructive pulmonary disease
  • diabetes
  • gastro-intestinal (e.g. coeliac disease, reflux, Chron’s disease)
  • mental health conditions (e.g. depression, anxiety)
  • obesity

How we can help.


We have established a team with specialist skills in the early detection and diagnosis of chronic disease and its ongoing management and treatment.
We aim to:
  • provide assistance, support and encouragement if you are suffering from a chronic condition
  • assess and routinely monitor your health (in conjunction with your doctor) to aid early detection/prevention/optimal treatment of your condition
  • provide you with practical advice/information/education on how to manage your condition as effectively as possible
  • assist with gaining access to government-funded plans and programs where eligible
  • assist with referrals to allied health professionals that will compliment your care
  • ensure your medical history remains current and up to date.

Meet our specialist team

Our specialist chronic disease management team (CDM Team) is qualified in this area of practice to support you to improve your wellbeing and optimise your health.

Our team includes:

Chronic Disease Management Team (CDM Team)

CDM Team - Healthy Lifestyle

Our CDM services and support

We offer a range of services and support which are tailored to suit your personal needs. Talk to us today to find out more.

GP Management Plans (GPMP) and Team Care Arrangements (TCA) – “Care Plans”
  • We map out the care and support that you will require to effectively manage your health condition(s) over a 12-month period.
  • We assist you to access rebated allied health sessions to help you treat and manage your condition more effectively (e.g. physiotherapy/dietitian/exercise physiology/podiatrist/chiropractor/osteopath).

SPMC Diabetes Care Program
  • We routinely monitor your diabetes in conjunction with your doctor.
  • We assist you to access rebated allied health sessions to help you manage symptoms and reduce complications of your diabetes (e.g. podiatrist/dietitian/exercise physiologist/physiotherapist).
  • We assist you to access additional rebated group sessions (e.g. dietitian/diabetic educator/exercise physiologist) if required.
  • We provide education and support to help you make the necessary changes required to improve the management of your diabetes.

Health Assessments
  • We assess your health at the key stages of your life where chronic disease development is more prevalent
  • Comprehensive health assessments aid early detection and treatment of chronic disease, which may help to prevent/lessen severity/delay onset and/or minimise complications.
  • We facilitate access to government funded programs if eligible.
  • We provide the following government funded health assessments:

Home Medicine Reviews

Our registered pharmacist is able to:
  • provide a comprehensive review of your current medication list
  • discuss any issues or concerns about your current medication list with your doctor
  • answer any questions you might have about the medicines you take
  • assist with transition to a Webster pack if necessary

Frequently Asked Questions

I have further questions about your services, who can I speak to?

Our reception team can take your questions and transfer you to our chronic disease management team if requested or required. Alternatively, please speak to your doctor or a member of our chronic disease management team at your next visit.

How do I make an appointment for a chronic disease management service?

Please contact our reception team.

Please note, as eligibility criteria apply for chronic disease management services, reception may need to consult with your doctor or a member of our chronic disease management team before finalising the appointment booking.


When was your last check-up?

We’re here to care for you. Regular visits with the CDM Team or your doctor will help to make sure any health issues don’t go undiscovered.




When was your last check-up?

With modern, busy lifestyles, it’s easy to neglect your health as you try to put everyone else’s needs first. We’re here to care for you. Regular visits with the CDM Team or your doctor will help to make sure any health issues don’t go undiscovered.

David Hall