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Chronic And Complex Management Plans

Did you know that if you are 65 years + and have a chronic medical condition that requires complex care needs, your General Practitioner (GP) can arrange a Chronic Disease Management Plan for you?

What is a Chronic Disease Management Plan (CDMP)

The Chronic Disease Management Plan (CDMP) is on the Medicare Benefits Schedule (MBS) and enables GPs to plan and coordinate the health care of patients with chronic or terminal medical conditions.

There are two types of CDMP plans that your GP can arrange for you.

  1. A GP Management Plan (GPMP) is a plan of action you have agreed to with your GP and provides an organised approach to care.
  • Identifies your health and care needs
  • Sets out the services to be provided by your GP
  • Lists the actions you can take to help manage your condition
  1. A Team Care Arrangements plan (TCA) can accompany your GPMP if you have a chronic medical condition and complex care needs requiring a multidisciplinary approach to care and provides;
  • Medicare rebates (if eligible) for certain allied health services as long as they are directly related to the management of your chronic condition
  • If eligible you can claim a maximum of five allied health services per calendar year
  • The five services can be provided by a single allied health provider or shared across different providers

What is a Chronic Medical Condition?

A chronic medical condition is one that has been (or is likely to be) present for six months or longer, for example, asthma, cancer, heart disease, diabetes, arthritis and stroke.

How It Would Benefit You:

If you have a chronic (or terminal) condition, with or without complex care needs, a CDMP will enable your GP to provide a structured approach to your care. It is a plan of action in which you agree management goals with your GP.

For example:

You may have heart disease and diabetes. With a CDMP arranged by your GP you could be provided with diabetic education from a diabetic educator and assistance to achieve your health goals from an Occupational Therapist. Your goals may be:

  • Increasing endurance for tasks such as gardening, shopping and bowls
  • Independently cook nourishing/diabetic meals and better manage your diabetes (as directed by the diabetic educator)
  • Incorporate a daily manageable exercise program

Other Eligible Allied health providers that may benefit you include:

  • Aboriginal health workers
  • Aboriginal and Torres Strait Islander health practitioners
  • Audiologists
  • Chiropractors
  • Diabetes educators
  • Dietitians
  • Exercise physiologists
  • Mental health workers
  • Occupational therapists
  • Osteopaths
  • Physiotherapists
  • Podiatrists
  • Psychologists
  • Speech pathologists
More Information:

For inquiries about eligibility, claiming, fees and rebates, call the Department of Human Services (Medicare): patient inquiries 132 011

Medicare Benefits Schedule

Chronic Disease ManagementClient Information Fact Sheet

Enable Equipment and Services


EnableNSW provide subsidised equipment and services to eligible people within NSW with chronic conditions or a disability to assist them with mobility, communication and self-care.

Enable NSW also provide financial assistance for people who have to travel significant distances to access specialist medical treatment which is not available locally.

As part of HealthShare NSW, EnableNSW is responsible for the administration of NSW Health disability support and other assistance programs.

Services Include:

Aids and equipment Program

The Aids and Equipment Program provides subsidised funded equipment for eligible people to assist with mobility and daily living needs. Equipment can include:

  • Shower commodes
  • Electric beds and accessories
  • Pressure care aids such as cushions and mattresses
  • Manual and electric wheelchairs
  • Transfer aids
  • Electric scooters

You can apply to EnableNSW yourself. Alternatively going through an Enable approved prescriber, such as an Occupational Therapist or physiotherapist, will ensure that you are applying for the aid/equipment that best suits your needs.

Requesting repairs

EnableNSW provides funding for servicing and reasonable repairs to items supplied by them. Please click here for guidance about who to contact for repairs.

Continence Aids Payment Scheme (CAPS)

The Continence Aids Payment Scheme or CAPS, is an Australian Government scheme that provides a payment to eligible people to assist with some of the costs of their continence products. You will need to fill out a CAPS application form that includes a health report by your health professional.

If you have any questions about the CAPS Scheme, please contact Medicare Australia on 132 011 and select option 1 or visit the CAPS website.

Home Respiratory Program

The Home Respiratory Program provides respiratory equipment including oxygen concentrators, continuous positive airway pressure (CPAP) machines, ventilators and respiratory consumables such as tracheostomy tubes to eligible people to manage their respiratory condition and maximise their independence in their own home. Download the Respiratory Program Fact Sheet and the Home Respiratory Program Forms & Guidelines

Prosthetic Limb Service

The Prosthetic Limb Service (formerly known as ALS) is responsible for funding the provision of artificial limbs to eligible people residing in NSW.

People requiring an artificial limb will consult with a clinical team consisting of a Rehabilitation Physician, Physiotherapist and Prosthetist to determine the most appropriate artificial limb for individual circumstances, within the guidelines of the scheme. These teams reside in clinics located across NSW.

Once a limb has been identified, the prescription is forwarded by the Prosthetist to EnableNSW for processing. People with limb deficiency or amputation interested in seeking further information about the prosthetic limb service should discuss their query with a health care provider.

Local Amputee Clinic/Prosthetic Limb Service in Newcastle:
  • TORONTO: Toronto Private Hospital – Day Rehab Area, South Wing Cnr Carey and Excelsior Parade Toronto NSW 2283, Director: Dr L Laycock Ph: 4950 0600
  • SHORTLAND: Hunter Valley Private Hospital Amputee Rehabilitation Clinic – Physiotherapy Gym, 20 Mawson Street Shortland NSW 2307 Director: Dr L Laycock Ph: 4950 0600
  • NEW LAMBTON: Rankin Park Hospital – The Limb Centre, Lookout Road New Lambton NSW 2305, Director: Dr P Gale – Attending PSP: Hunter Prosthetics & Orthotics Service Ph: 4921 4151
Communication Devises (visual and Audio)

The Communication Devises -EnableNSW have a number of speech and visual generating devices.

Isolated Patients Travel and Accommodation Assistance Scheme

The Isolated Patients Travel and Accommodation Assistance Scheme (IPTAAS) is a subsidy program which provides financial assistance to help with travel and accommodation costs for people (and eligible escorts) who need to travel long distances to access specialist treatment not available locally. Patients travelling at least 100km each way, or at least 200km per week cumulative distance, are eligible to apply for IPTAAS subsidies.

To obtain further details about IPTAAS eligibility, IPTAAS application forms and IPTAAS Fact Sheets, and to make an online IPTAAS application, go to EnableNSW IPTAAS

Navigating The Hospital System

it takes a Village understands that it can be tricky navigating the hospital system, facilities and procedures. It can be especially distressing when admitted because of an emergency.

Below you find links to information that will help guide and prepare you for a hospital stay or visit.

Can’t find what you are looking for? Does your health facility have advice for patients and carers not listed? Please contact [email protected] and we will be happy to add your information to our list.

Mental Health Services

Mental Health Care Plans

A mental health care plan is a plan for people with a mental health disorder. If you have mental health issues, your doctor can write out this plan.

A mental health care plan is available to you if you have a mental disorder that has been diagnosed by a doctor. Visit your doctor who will assess whether you have a mental disorder and whether you will benefit from a mental health treatment plan.

The Mental Health Care Plan is part of the Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule (Better Access) initiative. This initiative aims to improve outcomes for people with a clinically-diagnosed mental disorder.

For more information click ‘Care Plans

Specialist Mental Health Services For Older People (SMHSOP)

The Specialist Mental Health Services for Older People (SMHSOP) community Team provides co-ordinated services to older people with mental health problems.

These community teams have three major clinical functions; specialist mental health assessment, care planning and case management. Referrals are accepted from GPs as well as other health professionals but a medical referral is needed if diagnostic tests or medical treatment are needed.

Newcastle SMHSOP Services provide specialist consultation and liaison services (i.e. assessment, referral and training with primary care workers and GPs, residential service providers and others) to address the needs of the older people with mental health problems.

Prevention and early intervention is a key part of the Specialist Mental Health Services for Older People (SMHSOP) community team’s activity. Specialist workers within SMHSOP focus on suicide and depression prevention in older people.

For more information click on the Hunter New England Health Fact Sheet

Contact details for SMHSOP Newcastle:

The McAuley Centre, The Mater Hospital, Edith Street, Waratah. Ph. (02) 4033 5600

Other Useful NSW Government Services

  • Department of Veteran Affairs
  • Medical Energy Rebate – Department of Resources and Energy is able to assist people to pay their electricity bills if they, or someone living with them, have an inability to self-regulate body temperature when exposed to extreme (hot or cold) environmental temperatures. It is associated with certain medical conditions such as Parkinson’s disease and Multiple Sclerosis. However, to be eligible for the rebate a patient will require a separate diagnosis that they are unable to self-regulate their body temperature.
    • The Medical Energy Rebate provides:
      • $285 ex. GST (was $235) per year to eligible customers who hold an electricity account with an electricity retailer of their choice; or,
      • $314 (was $258.50) a year to eligible residents of on-supplied residential communities, retirement villages and strata schemes
  • Help with Housing: NSW Family & Community Services – Under Housing Pathways, if eligible, you can apply for public housing, Aboriginal housing and community housing. You can also apply for private rental assistance or for a transfer if you already live in social housing.
  • Lifetime Care and Support Authority: If you’ve been severely injured in a motor accident in NSW from 1 October 2006 (for children under 16) or from 1 October 2007 (for adults), you may be eligible for this scheme.
  • Palliative Care – Directory of Services (PDF)
  • Technology for Independence: Provides helpful information in regard to technology to increase independence.
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