GP Care Plans • AGPAL Accredited

Chronic Disease Management Hervey Bay

Living with a chronic condition often means ongoing reviews, medication adjustments and support to stay on track. At Main Street Medical Centre in Pialba, our GPs provide structured chronic disease care using GP Chronic Condition Management Plans (care plans) to help coordinate your treatment and referrals.

Book Care Plan Appointment Call (07) 4325 4000

Your Chronic Disease Management at Main Street Medical Centre

Care plans with your regular GP to support continuity of care

Access to Medicare-subsidised allied health services with referral — usually up to 5 per calendar year, or up to 10 for eligible Aboriginal and Torres Strait Islander patients

Nurse-supported chronic disease follow-up and coordination

Reviews as clinically appropriate (often up to every 3 months)

AGPAL accredited practice with 40+ years experience

Coordinated referrals to allied health, pathology, imaging and specialists when needed

What is Chronic Disease Management?

Chronic disease management is a structured approach for people with ongoing conditions that need regular monitoring and coordinated care. Under Medicare’s GP Chronic Condition Management Program, your GP can prepare a GP Chronic Condition Management Plan that documents your goals, key treatments, and referrals to other providers where appropriate. At Main Street Medical Centre, we focus on practical, coordinated care—so your appointments, tests and referrals are easier to keep on top of, and your progress is reviewed over time. Our nursing and admin teams help support recalls and coordination so important follow-ups don’t get missed. Learn more about chronic conditions from the Australian Institute of Health and Welfare .

Chronic disease management consultation at Hervey Bay GP clinic

40+ Years Serving Hervey Bay

Chronic Conditions We Manage in Hervey Bay

Our GPs support patients living with a wide range of long-term conditions. Whether you’ve been recently diagnosed or you’re looking for better control, we can tailor a plan to your circumstances.

Type 2 Diabetes

Medication review, pathology monitoring, lifestyle support, and complication screening (including feet and kidneys).

Heart Disease & High Blood Pressure

Cardiovascular risk reduction, BP control, cholesterol management, and prevention planning.

Asthma & COPD

Action plans, inhaler technique checks, flare-up prevention and coordination of lung function testing where needed.

Arthritis & Osteoporosis

Pain strategies, mobility and falls prevention planning, bone health monitoring, and allied health coordination.

Mental Health Conditions

Support for anxiety and depression as part of whole-person care (and referrals to appropriate mental health services when needed).

Thyroid Disorders

Ongoing monitoring, medication adjustment and symptom reviews to maintain stable thyroid levels.

How Chronic Disease Management Works

Your care plan follows a clear pathway designed to support safe, coordinated care over time. Here’s what to expect when you book chronic disease management in Hervey Bay with our practice.

Care Plan Appointment (GPCCMP)

Your GP completes an assessment of your conditions, current treatment, tests and goals, then prepares a GP Chronic Condition Management Plan (commonly billed to Medicare as item 965 when clinically eligible). You’ll receive a copy, and with your consent we can share relevant information with referred providers.

Referrals for Allied Health (Medicare-subsidised)

If appropriate, your GP can refer you to allied health professionals (for example physiotherapy, podiatry, dietetics, exercise physiology and others). Eligible patients can access up to 5 Medicare-subsidised allied health services per calendar year (services reset each 1 January). Eligible Aboriginal and Torres Strait Islander patients may access up to 10 services in total under the relevant arrangements. Your GP confirms eligibility and referral needs. Some providers may charge a gap.

Reviews to Track Progress

Your GP reviews your plan as clinically appropriate (often up to every 3 months). Reviews are commonly billed as item 967 when eligible. Reviews are a chance to check progress, adjust treatment, update referrals and keep your care coordinated.

Ongoing Support Between Reviews

Depending on your needs, the practice team may help with coordination, recalls, monitoring and follow-up consistent with your plan. Ask your GP what support is appropriate for your situation.

GP discussing chronic disease care plan with patient in Hervey Bay

Why Choose Main Street Medical Centre for Chronic Disease Management?

For over 40 years, Main Street Medical Centre has supported the Hervey Bay community with long-term, relationship-based general practice care. Chronic disease management works best when your GP understands your full history and you have consistent follow-up over time. We use structured workflows and proactive reminders to support appropriate reviews, monitoring and referrals. Our nursing and admin teams work closely with our GPs to help coordinate your care. If you’re registered with MyMedicare, Medicare-funded preparation and review of your GP chronic condition management plan must be through your registered practice. If you’re not registered, these services are provided through your usual GP.

Chronic Disease Management Costs

We aim to make chronic disease care as accessible as possible. If you’re eligible for Medicare and your appointment is suitable for bulk billing, your GP can bulk bill the consultation (including care plan appointments). Some services and providers (especially allied health) may have out-of-pocket costs.

$0 Bulk billing may apply For eligible Medicare patients and appointment types

View our fee schedule for consultation types and any out-of-pocket costs.

Our GPs for Chronic Disease Management in Hervey Bay

All of our GPs can help with chronic disease management and care plans. You can book with your usual GP for best continuity.

Dr Ramani Poonehela

MBBS, FRACGP • 20+ Years

Menopause & HRT Thyroid

Dr Tin Aung

MBBS, Dip Med Sci, FRACGP

Women’s Health Chronic Care

Dr Yan Paing Oo

MBBS, FRACGP

Chronic Care Iron Infusions

Dr Zin Zin Thant

FRACGP

Chronic Care Women’s Health

Dr Katherine Sparks

MD (Griffith), BHlthSc

Nutrition Geriatric Care

View all our doctors →

Frequently Asked Questions About Chronic Disease Management

Who is eligible for a chronic disease care plan?

You may be eligible if you have a chronic (or terminal) medical condition that has been present for at least 6 months, or is expected to last 6 months or more, and you would benefit from a structured plan and coordinated care. Your GP will confirm eligibility during your appointment.

How many allied health visits can I access with a care plan?

Eligible patients can access up to 5 Medicare-subsidised allied health services per calendar year (with referral). Eligible Aboriginal and Torres Strait Islander patients may access up to 10 services in total under the relevant arrangements. These reset on 1 January. Your GP confirms eligibility and referral needs; providers may charge a gap fee.

How often do I need to see my GP for care plan reviews?

Reviews are done as clinically appropriate—often up to every 3 months—so your GP can track progress and adjust treatment. Your GP will recommend a review schedule that suits your condition(s).

Do I need to be registered with MyMedicare?

MyMedicare registration is voluntary. If you are registered, Medicare-funded preparation and review of your GP chronic condition management plan must be through your registered practice. If you are not registered, you can access these services through your usual GP. Reception can assist with registration.

Is chronic disease management bulk billed at your practice?

Bulk billing may apply for eligible Medicare patients and appointment types, including care plan appointments where appropriate. Some services and some providers (particularly allied health) may have out-of-pocket costs. Please see our fees page for details.