Chronic Disease Management

Chronic disease is very common in Australia, with over half the population suffering from at least one chronic illness. The incidence of many of these chronic health conditions are on the rise due to factors such as change in lifestyle and increased life expectancy.  They can lead to disability and premature death however with appropriate management, a team-based approach and a healthy lifestyle people can live healthier and longer lives with their chronic condition.

What is a Chronic Health Condition?

A Chronic health condition is a long-term illness that lasts at least 6 months or longer and often gets worse over time. They often can’t be cured, but by taking an active role in looking after yourself and receiving appropriate medical care it can be managed. According to the Australian Institute of Health and Welfare, 61% of Australian’s have at least 1 of the major 8 Chronic conditions. These include

  • Arthritis
  • Asthma
  • Back pain
  • Cancer
  • Cardiovascular disease
  • Chronic Obstructive Pulmonary Disease
  • Diabetes
  • Mental Health Conditions

Remember this list is only the ‘top 8’ and is by no means complete. Other chronic diseases with significant burden on our health include dementia, osteoporosis, stroke, epilepsy, Parkinson’s disease, inflammatory bowel disease, multiple sclerosis and many more.


Management of Chronic Health Conditions:

Often patients can have more than one chronic disease and management can seem quite complex and overwhelming.  Learning as much as you can about your medical conditions and finding reliable information can help you take control of your health. Having a team of healthcare providers and a good support network will also improve the management of your health conditions.

1) Have a good GP

Ensure you have a good, regular GP that can help you take control of your health.  They should be familiar with all your health conditions and coordinate your care. This will include conducting regular health checks, managing your medication, referring to specialist and other health care providers involved in your care. Your regular GP can also formulate a GP Management plan (GPMP)  for your chronic health conditions to help you achieve your health goals.

 2) Healthy Lifestyle

Before we jump to medication, the key to managing any chronic health conditions is a healthy lifestyle.  This can be achieved by;

  • Stopping smoking
  • Doing as much physical activity as your condition will allow
  • Reducing alcohol intake
  • Eating well
  • Maintaining a healthy weight
  • Good sleep hygiene – avoid napping during the day where possible and avoid stimulants such as caffeine before bed so you can have a good night sleep.

3) Team Based approach

For complex medical conditions a health care team approach is recommended to help you achieve your health goals. This may include a medical specialist and other allied health professionals. For example – a diabetic patient may involve a diabetes educator, dietitian, podiatrist, exercise physiologist and an ophthalmologist involved in their health care. Your GP can coordinate these referrals and arrange a Team Care Arrangement (TCA).

4) Medication

Be familiar with the medication you are taking and why. Make sure you review them regularly with your doctor and let them know if you are experiencing any side effects. Discuss with your GP  or pharmacist what other over the counter medications or supplements you are taking to ensure there are no medication interactions. Your pharmacist can help with a Home Medication Review (HMR) especially if you are on more than 5 tablets a day and are having difficulty managing your own medications. They can also make up a dosing pack (webster pack) to help you keep track of when you should be taking your tablets and to avoid medication errors.

5) Look after your mental health

Having a chronic health condition can have a huge impact on your mental health. Chronic disease can be overwhelming and often causes tiredness, pain, stress, and limits what you can and can’t do.  This can be hugely frustrating and can take a big toll mentally.  Research shows that if you improve your mental health, it can also improve your physical health. Please talk to your doctor about how your chronic health condition is affecting you emotionally. They can offer further support such as referring you to a psychologist , social worker or other support groups.

6) Support

Social support is important in the management of chronic health conditions. This may come in the form of both emotional and practical support (such as transport and assistance in attending appointments). It is important to catch up with family and friends on a regular basis and let them know how they can help you. Support groups can help improve your knowledge about your condition and connect you with people that are going through what you are experiencing.  Talk to your doctor or health professional about what suitable support groups are out there for you.


Chronic Disease Management Plans

To assist you in managing your chronic health conditions and achieving your health goals your GP can provide you with a GP Management Plan. This will includes identifying your health needs, goals that you hope to achieve , and a treatment plan including lifestyle measures.  Once a plan is in place it should be reviewed and updated regularly by your GP.

If you have complex care needs which require the involvement of other health providers, such as a physiotherapist, dietician, podiatrist etc, you may be also be eligible for a Team Care Arrangement (TCA). This will enable you to receive a Medicare rebate when you visit specific private allied health services providers for up to 5 sessions per calendar year. In most cases there will still be some out of pocket expenses which still count towards the extended Medicare safety net. Not everyone qualifies for a Team Care Arrangement so please check with your GP if you are eligible.



Taking an active role in the management of your chronic health condition can improve your quality of life. This can be achieved by having

  • A good regular GP
  • A healthy lifestyle including eating well, being physically active, not smoking and reducing alcohol intake.
  • Taking your prescribed medication.
  • A team-based approach with other health professionals and support services
  • A comprehensive management plan


Resources  13 11 14




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