
Chronic Disease Management
Our Chronic Disease Management service is designed to support patients living with long-term health conditions by providing comprehensive, proactive care in the comfort of their homes. We specialise in managing a range of chronic conditions, including diabetes, chronic kidney disease, chronic heart failure, and chronic obstructive pulmonary disease (COPD). Our team works collaboratively with patients, families, and healthcare providers to create personalised care plans focused on early intervention, symptom management, and overall well-being. By utilising advanced remote monitoring and timely medical interventions, we help reduce hospitalisations, improve quality of life, and empower patients to take control of their health with confidence and ease.
Conditions treated :
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COPD – (breathing problems)
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CCF - (Heart failure)
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Type 2 diabetes
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Kidney disease
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Hypertension
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Neurodegenerative problems -Delirium Management in dementia, aspiration pneumonia
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Urinary tract infections and constipation management in stroke patients and MS patients
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Dementia care -Memory (Cognitive) assessment and regular monitoring of the memory decline and appropriate management plans
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Falls work up and management
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NDIS Clients with complex medical disease: Cerebral Palsy, epilepsy, recurrent chest infections, diabetes
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Residential clients where chronic disease monitoring is done by regular review of medical condition and blood tests to optimise the health care needs
Services :
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Clinical consultations
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Chronic Disease monitoring,
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Patient/staff education
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Medication rationalisation and deprescribing
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Complex care planning, advance health care directive