Chronic Disease Management and Coordination

Our Chronic Disease Management service is coordinated by a full time care coordinator supported by clinical staff.

Their role includes the identification, clinical management, recall and ongoing support of patients who require chronic disease management, Annual Health Assessments (AHA), Disability AHA, Veterans Affairs CVC, and nursing home CMAs.

The coordinators also support patients with access to social services such as:

Enhanced Primary Care

The care coordinator also attends family conferences in nursing homes and the local hospital and reports back to the patient’s General Practitioners.

Your doctor will be able to discuss your eligibility for a Care Plan and referral for allied health appointments under the Enhanced Primary Care arrangements.

Our Care Co-ordinator is able to assist you in making these appointments and to answer any questions or concerns you may have.

GP Management Care Plans

All our GP’s at Inglis Medical provide GP Management Care Plans and Team Care Arrangements for patients with chronic medical conditions.

These then form a framework in which patients and GP’s can establish individual goals and actions to reach these goals. These are then reviewed with the patient each 3 to 6 months.