Our patients with a chronic or terminal medical condition and complex care needs may require care from a multidisciplinary team.

A chronic medical condition is one that has been (or is likely to be) present for six months or longer, for example, asthma, cancer, cardiovascular disease, diabetes, musculoskeletal conditions and stroke. Our doctors are involved in the assessment the patient, agreeing management goals with the patient, identifying actions to be taken by the patient, identifying treatment and ongoing services to be provided, documenting these and including a review date in the GPMP.

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