For health professionalsContact us(08) 6110 0570admin@pdchealthhub.com.au
Diabetes Education

Integrated Chronic Disease Management

Coordinated, team-based care across PDC Health Hub’s clinical disciplines for patients managing complex or multiple chronic conditions, with shared care planning and regular clinical communication.

#00648d

About this service

Managing a single chronic condition well is challenging. Managing two, three, or more simultaneously, with multiple clinicians, medications, and monitoring requirements, can feel overwhelming for patients and complex for treating teams. PDC Health Hub’s integrated chronic disease management model is designed specifically for this challenge.

By co-locating diabetes educators, dietitians, exercise physiologists, podiatrists, pharmacists, and physiotherapists under one roof, PDC Health Hub enables genuinely coordinated care that reduces fragmentation, eliminates conflicting advice, and keeps every clinician on the same page.

What integration looks like in practice

  • Shared patient records and clinical communication across disciplines
  • Joint care planning for patients with complex comorbidities (e.g. T2DM + CKD + cardiovascular disease)
  • Cross-referral pathways within the clinic: no GP referral required for internal referrals
  • Coordinated appointment scheduling to reduce patient burden
  • Consistent messaging across clinicians on lifestyle, medications, and goals
  • Participation in GP-organised case conferences and shared care plans

Patients who benefit most

  • Type 2 diabetes with cardiovascular disease, chronic kidney disease, or obesity
  • Type 1 diabetes requiring coordinated medical, dietetic, and technology support
  • NDIS participants with complex allied health needs across multiple disciplines
  • Older Australians with polypharmacy and multiple chronic conditions
  • Patients transitioning from hospital to community care

To discuss a referral or care coordination arrangement, please contact PDC Health Hub reception. We welcome referrals from GPs, specialists, hospitals, and NDIS Support Coordinators. Learn more about coordinated care at PDC Health Hub.

What is involved

Integrated Chronic Disease Management
At a glance
Team
Diabetes Education
Session length
Funding
Telehealth
Referral
Booking
Online, or call (08) 6110 0570

More from this team

Most people use more than one service over time. Every service here works from the same shared plan, so you never have to start your story again.

Explore all services

How it works at PDC

Three steps from your first call to a plan the whole team can see.

1

Book your first visit

Book online or call (08) 6110 0570. If you have a GP referral or care plan, bring it with you or ask your GP to send it to us.

2

Assessment and goals

Your clinician takes a full history, asks what matters most to you and agrees goals you can work towards together.

3

One plan, one team

With your consent, your plan is shared with your GP and with other PDC clinicians you see, so everyone works from the same page.

Common questions

Do I need a referral?
+

Most of our services can be booked without one. You do need a GP referral to claim a Medicare rebate, and a Home Medicines Review or Residential Medication Management Review always starts with a GP referral. NDIS, DVA and workers' compensation claims each have their own paperwork. If you are not sure, call us on (08) 6110 0570 and we will check before you book.

Can I claim a Medicare rebate?
+

If your GP has prepared a GP Chronic Condition Management Plan and referred you to us, Medicare pays a rebate for up to five eligible allied health visits a calendar year, shared across disciplines. Private health cover may also contribute, depending on your policy. We confirm what applies to you when you book.

Can I be seen by telehealth?
+

Many of our services can be delivered by secure video call. Where a service needs a hands-on assessment, such as a foot or physiotherapy examination, we will book you in person at one of our ten clinics.

What should I bring to my first appointment?
+

Your referral or care plan if you have one, a list of your current medicines, any recent test results, and your Medicare, DVA or NDIS details. If you use a glucose meter, CGM or insulin pump, bring that too.

Can someone come with me?
+

Yes. A family member, carer, interpreter or support worker is welcome at any appointment. If you need an interpreter, let us know when you book.

Ready to get started?

Book online in under a minute, or call and our care team will check this is the right place to start.

Or go straight to a service

Phone (08) 6110 0570 · Medicare, NDIS, DVA and private options across our services

For GPs and health professionals

Referring a patient for this service?

Send an online referral in under two minutes. One referral reaches every discipline at PDC Health Hub.