Chronic Disease Management & Mental Health Treatment Plans

In this situation, any medical condition that lasts 6 months or more is considered a chronic disease.  A typical example is Type 2 diabetes, which may involve seeing different types of health practitioners over a period of many years.  Other examples include heart disease (eg after a heart attack), COPD, some types of arthritis, or kidney disease.  Children and young people may also qualify with conditions such as autism spectrum disorder, cerebral palsy, cystic fibrosis.  Chronic pain is another condition that can benefit from comprehensive care plans.

Yes, for people with chronic conditions Medicare can allow this.  But the purpose of the system is not just to write referral letters!  Your GP and probably the practice nurse will need to take quite a bit of time planning your care and setting up the system before any referral can be written.  You will not qualify for a referral unless you have a chronic condition that will last 6 months or more and benefit from allied health referral, so please understand if your GP decides that you are not eligible.

 Step 1:

Do you have a regular GP?  If not, we strongly recommend that you find a GP that you can get to know, that can understand your specific needs and follow you up for the foreseeable future.  We have lots of evidence to show that people are healthier when they have a GP that they know and trust.  Ask yourself whether there is someone that knows your medical story, but also knows you as a person and your preferences?  This is what a good GP will want to do.

Step 2:

Make an appointment with your GP to create a management plan.  Make sure you tell the receptionist that it is a management plan that you need, as these often need extra-long appointments.  Sometimes a practice nurse will help with this process as well. At Royal Park Medical, we will often take up to an hour to develop your management plan (some time with the nurse then some time with the GP).

A good GP Management Plan should be just that – a clear plan for the management of your health.  It is a written (or computer) document that will outline all the steps that need to be taken over the next 1-2 years.  This includes things your doctor needs to do, things you need to do, and things other health practitioners need to do.  It will make clear who will do what, and when they will do it.

Your GP or nurse will discuss those steps with you in some detail.  They will want to hear your preferences, and will write down the goals that you are setting yourself.  They will help you to understand what targets you should be aiming for.  For example, if you want to lose weight, they will write down how much weight you plan to lose and a reasonable time frame.  The GP will offer you a copy of your plan to keep and to share with other health practitioners that you see.

Medicare updated the process for Management Plans in 2025.  The intent is the same, and you can still have referrals to allied health, but only one document is needed (no separate Team Care Agreement is required).

This is frequently misunderstood.  Eligible people can have up to 5 visits in any calendar year.  These 5 visits can all be used for one practitioner (eg your physio) or can be split up between different practitioners (eg 2 for a diabetes educator and 3 for a dietician). On January 1^st each year, you become eligible for 5 new visits. You will need a new referral once you have used up all 5 visits. If you don’t use all 5 visits before 31 December, they do not carry over into the next year.

Aboriginal and Torres Strait Island people can access up to 10 rebates per year.

If you develop a new condition, or your care needs change significantly (eg if you are admitted to hospital and have a new medical problem to manage), your doctor can either adjust your treatment plan or write a whole new one.  When you are discharged from hospital it is a good idea to book into your GP soon afterwards to discuss how your plans may change.

Perhaps the most important step of all!  Management plans need to be reviewed every few months.  There seems no point in writing a plan and setting individual goals if you don’t go back to it later and see how much progress you have made.  Make sure you ask your GP when they think you should review the plan, and book a dedicated appointment for this purpose.  There must be at least 3 months between the reviews.

If you have met your goals, well done!  Now you can set new goals for yourself and ask the GP to add them to your plan.  If you are not there yet, perhaps the targets need to be adjusted.

Medicare rebates for these review appointments are higher than standard appointments.  This means you will be less out of pocket if you review your GP Management Plan regularly.

Medicare rebates are available for patients, who have been assessed by their GP, to be experiencing a mental health disorder. Their GP can refer the patient for up to ten individual and ten group allied mental health services per calendar year on a GP Mental Health Treatment Plan.

Mental health services under this initiative include psychological assessment and therapy services provided by clinical psychologists, and focussed psychological strategies services provided by appropriately qualified GPs and eligible psychologists, social workers and occupational therapists.

The Better Access initiative is available to patients with an assessed mental health disorder who would benefit from structured psychological support. Mental health disorder is a term used to describe a range of clinically diagnosable conditions that significantly interfere with an individual’s cognitive, emotional or social abilities. These can include depression, anxiety, OCD and PTSD. Dementia, delirium and mental retardation are not regarded as mental health disorders for the purposes of this initiative. Nor is relationship and/or marriage counselling considered an eligible condition.

Step 1:
Visit your GP who will assess whether you have a mental health disorder and whether the preparation of a GP Mental Health Treatment Plan is appropriate for you, given your health care needs and circumstances. If so, together you will complete a GP Mental Health Treatment Plan.  These can take some time, so please understand if your doctor needs to schedule another appointment to complete it. Sometimes it may be necessary to refer you to a psychiatrist or paediatrican for an assessment and diagnosis.

Step 2:
Your GP, psychiatrist or paediatrician can initially refer you for a course of treatment (up to six individual and six group allied mental health services), which may comprise of psychological assessment and therapy by a clinical psychologist or focussed psychological strategies by an allied mental health professional. It is at the clinical discretion of your referring practitioner as to the number of allied mental health services you will be referred for (a maximum of six in any one referral).

Step 3:
Depending on your health care needs, following the initial course of treatment (a maximum of six services but may be less depending on your clinical need), you can return to your GP, and obtain a new referral to obtain an additional four sessions (up to a maximum of ten individual and ten group services per calendar year).

This information is intended to support, not replace, discussion with your doctor or healthcare professional. The authors have made considerable effort to ensure the information is accurate, up to date and easy to understand. Royal Park Medical accepts no responsibility for any inaccuracies, information perceived as misleading, or the success of any treatment regimen.