Commitment to Community Health
We prioritize the health and wellbeing of our local community through comprehensive chronic disease management. Our team of dedicated doctors is committed to providing tailored care and support for patients living with chronic medical conditions.
Understanding Chronic Medical Conditions
A chronic medical condition is defined as a health issue that has persisted for six months or longer. Common examples include:
- Asthma
- Cancer
- Cardiovascular Disease
- Diabetes
- Musculoskeletal Conditions
- Stroke
- Chronic obstructive pulmonary disease (COPD)
Our goal is to assist you in managing these conditions effectively, enhancing your quality of life.
Chronic Disease Management Plans
To ensure structured and effective care, we offer Chronic Disease Management Plans (CDMPs) designed specifically by our general practitioners for patients with complex, ongoing health needs.
A GP Management Plan (GPMP) provides a comprehensive roadmap for your healthcare. This plan:
- Identifies your health and care needs: We work closely with you to assess your specific requirements.
- Outlines the services provided by your GP: Our team will detail the support and treatment you can expect from us.
- Lists actionable steps for managing your condition: Together, we will create a plan that empowers you to take control of your health.
Team Care Arrangements
For patients with chronic medical conditions that require multidisciplinary care, we may also implement Team Care Arrangements (TCAs). These arrangements enable us to collaborate effectively with other health providers to deliver coordinated care tailored to your needs. Key aspects of TCAs include:
- Collaboration with at least two other health or care providers
- Coordination of ongoing treatment and services
- Open communication while respecting your privacy—let us know if there are areas of your care you prefer to keep private.
Regular Reviews
Regular reviews are crucial to the success of your chronic disease management plan. During these check-ins, your GP will:
- Assess your progress toward your health goals
- Discuss any changes to your plan that may be necessary
- Adjust your management strategy based on your feedback and current health status
This ongoing evaluation ensures that your care remains effective and responsive to your needs.
Accessing Care Plans
We offer chronic disease management plans to all eligible patients at little or no cost. To determine eligibility, we encourage you to book an appointment with your GP.
Our practice nurse will provide additional support and monitoring between visits, ensuring continuity of care and addressing any concerns that may arise.