The Chronic Care Clinic helps a growing number of people in the community manage and care for conditions that are long-lasting and persistent.
Led by our team of nurses, patients with chronic disease or pain receive special attention through health assessments and a chronic care plan to improve and manage their condition and their quality of life.
Common chronic conditions such as arthritis, asthma, back pain, cancer, cardiovascular disease, pulmonary disease, diabetes, kidney disease, osteoporosis, and mental health are just the tip of the iceberg when it comes to chronic care. If you suffer from these or another chronic disease proper care is needed.
We take chronic care and preventative health seriously, a 45 – 75-minute assessment with a nurse, followed by a doctors’ appointment, helps chart a care plan tailored to your specific chronic disease and lifestyle.
With prevention always at the forefront of our thinking nurses liaise with patients allied health and specialist practitioners to ensure a multidisciplinary approach.
The very nature of chronic disease requires follow-up and review booked with the patient every 3-6 months.
If your health suffers from chronic disease, it needs proper care and management. Visit our chronic care clinic today.
Available Health Assessments
Type 2 Diabetes Risk Assessment (Ages 40–49)
Eligibility: People aged 40–49 years identified as being at high risk of developing type 2 diabetes, based on the Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK).
Medicare Frequency: Once every 3 years
Chronic Disease Risk Health Assessment (Ages 45–49)
Eligibility: Patients aged 45–49 years who are at risk of developing a chronic disease.
Medicare Frequency: Once only
Heart Health Check
Eligibility: Adults at risk of cardiovascular disease, including those with risk factors such as smoking, high blood pressure, high cholesterol, diabetes, or a family history of heart disease.
Medicare Frequency: Once every 12 months
Menopause / Perimenopause Health Assessment
Eligibility: Women experiencing menopausal or perimenopausal symptoms.
Medicare Frequency: Once every 12 months, available for an initial two-year period
75+ Years Annual Health Assessment
Eligibility: Patients aged 75 years and older.
Medicare Frequency: Once every 12 months
Additional Medicare-Supported Assessments
We also provide health assessments for eligible patients under the following groups:
- Aboriginal and Torres Strait Islander Peoples (available annually)
- People with an intellectual disability (available annually)
- Refugees and humanitarian entrants (once only)
- Former Defence Force members (once only)
- Residents of aged care facilities (available annually)
What’s included?
Each health assessment may include:
- Review of personal and family medical history
- Blood pressure, weight, and BMI measurement
- Lifestyle assessment (diet, physical activity, smoking, alcohol)
- Mental health and memory screening
- Falls risk and mobility review
- Preventive screening and immunisation status
- Care planning and referrals (as needed) All assessments are completed by a practice nurse and reviewed by your GP. Follow-ups are scheduled every 3–6 months, or sooner as needed.
Quick Reference Table
| Health Assessment | Eligibility | Frequency |
|---|---|---|
| T2DM Risk (40–49 yrs) | Aged 40–49 + high diabetes risk | Every 3 years |
| Chronic Disease (45–49 yrs) | Aged 45–49 + risk of chronic illness | Once only |
| Heart Health Check | At risk of heart disease | Every 12 months |
| Menopause / Perimenopause | Experiencing menopausal symptoms | Annually (For 2 years) |
| 75+ Health Assessment | Aged 75+ | Every 12 months |
Why choose our Chronic Care Clinic?
- Medicare-funded assessments for eligible patients
- Experienced, multidisciplinary team including nurses, GPs, and allied health
- Continuity of care through structured follow-ups and care plans
- Focus on prevention, early intervention, and long-term wellbeing
Book your assessment today by calling our reception team or by clicking “Book” at the top of the web page.
Let us help you take the next step toward better health.
