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Your Diabetes Care Plan, Explained
Evidence-Based Health Education

Your Diabetes Care
Plan
, Explained

A structured care plan brings your GP, practice nurse and allied health team together so nothing falls through the cracks. Here is how a GP diabetes care plan works at Iluka Medical Centre in Perth's northern suburbs, and what Medicare now covers.

Updated 8 July 2026
AHPRA & RACGP Compliant
14 references
A GP-led diabetes care plan covers medications, nutrition, activity, monitoring, diabetic foot care and regular reviews.
A GP-led diabetes care plan covers medications, nutrition, activity, monitoring, diabetic foot care and regular reviews.
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Medically reviewed by the GP team at Iluka Medical Centre Iluka WA 6028 · Last reviewed 8 July 2026 · Aligned with RACGP and current Medicare (MBS) guidance
General health information only. This article is based on current Australian guidance and does not replace personal medical advice. Your diabetes care should be individualised by your own GP. Please book an appointment to discuss what is right for you.
▼ Risk
5.6%
Lower 10-year heart attack risk when targets are met[5]
HbA1c
0.5%
Average HbA1c improvement with structured care[5]
▲ Goals
12%
More likely to reach diabetes targets with a plan[3][4]
Medicare
5
Rebated allied health visits per calendar year[10][11]

The Five Pillars of a Diabetes Care Plan

🩸
Glucose Control
Personalised HbA1c goal
❤️
Heart & Kidney
Organ protection
🦶
Foot & Eye Checks
Annual cycle of care
🤝
Team Care
Allied health support
📋
Medicare
Bulk-billed reviews
🧬

Type 1 and Type 2: What's the Difference?

Two conditions, two approaches

Both types raise blood glucose, but for different reasons, and getting the type right shapes your whole plan.

Type 1 Autoimmune
  • The immune system destroys the insulin-making cells[1]
  • Insulin is needed for life, from diagnosis[1][8]
  • Not caused by lifestyle
Type 2 Insulin resistance
  • The body resists insulin and makes less over time[2]
  • Often linked to lifestyle and family history[2]
  • Managed with lifestyle, tablets, injectables or insulin[2]
A structured care plan makes reaching your targets more likely
The GPCCMP replaced the old GP Management Plan & Team Care Arrangement on 1 July 2025
Care plan and one quarterly review bulk billed Mon–Fri; up to 5 rebated allied health visits a year
Foot, eye and kidney problems often start with no symptoms — screening finds them early
🎯 Quick Reference: Targets
HbA1c (most adults)
≤7.0% (53)
Blood pressure
≤140/90
BP if kidney disease
<130/80
Activity per week
150 min
Resistance sessions
2–3 / wk
Targets are individualised. Your GP sets what is right for you. [9]

Talk to Your GP

Set up or review your diabetes care plan with the team at Iluka Medical Centre.

Book an Appointment

📞 (08) 6119 4700

Plaza Shopping Centre, 1st Floor,
98 O'Mara Boulevard, Iluka WA 6028 · Open 7 Days

📋

How a Care Plan Improves Your Outcomes

Coordinated care, measured results

A structured plan works by making sure nothing is missed. People with a comprehensive care plan are around 12% more likely to reach their diabetes targets, and reaching those targets meaningfully lowers long-term risk.[3][4][5]

Meeting your targets lowers 10-year risk of[5]

Heart attack −5.6%
Stroke −2.4%
Kidney failure −1.3%
📅

What's Inside Your Plan

Goals, monitoring and the annual cycle of care

Your GP confirms your diabetes type, checks your control, screens for early complications and sets goals with you.[7][9] Your plan then sets a monitoring rhythm known as the annual cycle of care.

Check How often Why it matters
HbA1c blood test 3–6 months Tracks average glucose control
Blood pressure & cholesterol Each review Protects heart and vessels
Kidney function (urine & blood) Yearly Detects early kidney change
Comprehensive foot check Yearly Prevents ulcers and nerve damage
Eye screening Yearly Catches retinopathy early
🦶 Why diabetic foot care matters: diabetes can damage the nerves and blood vessels in your feet, often without early symptoms. Regular podiatry checks help identify risk early and prevent serious complications.[12][14] Ask our team about on-site podiatry.
💊

Your Treatment Plan

Tailored to your type and your risks
Type 1 Insulin-based
  • Insulin by injections or a pump[1]
  • Glucose monitoring, including continuous options
  • Carb counting and hypo management[1]
Type 2 Stepped care
  • Healthy eating and activity first[2][9]
  • Usually metformin, then added medicines[2]
  • Injectables often tried before insulin[2]

The RACGP recommends at least 150 minutes of activity a week plus two to three resistance sessions, alongside healthy eating.[9]

❤️ Heart or kidney disease changes things: if you have heart disease, heart failure or kidney disease, certain medicines (SGLT2 inhibitors or GLP-1 receptor agonists) are recommended to protect those organs, regardless of your blood sugar level.[2][9]
🗂️

Medicare, Bulk Billing & Your Plan

What changed on 1 July 2025

From 1 July 2025, the older GP Management Plan and Team Care Arrangement were replaced by a single GP Chronic Condition Management Plan (GPCCMP).[10][12] If diabetes is affecting your health, you are likely to be eligible.

Individual Services
  • Up to 5 allied health visits per calendar year[10][11]
  • 10 for Aboriginal & Torres Strait Islander patients
  • Dietitians, podiatrists, exercise physiologists, diabetes educators
Group Services (Type 2)
  • Assessment, then up to 8 group services a year[10][11]
  • Diabetes education, dietetics or exercise physiology
Bulk-billed care plans and reviews at Iluka (Mon–Fri). Your diabetes care plan and one three-monthly review appointment are bulk billed Monday to Friday, so you have one bulk-billed visit focused on your diabetes management each quarter. Weekend appointments are privately billed. Book your care plan appointment[10][11]
ℹ️ Already have an older plan? Plans made before 1 July 2025 stay valid, and you can use services under them until 30 June 2027. Referrals are now made by a simple referral letter rather than the old form.[10][11][12]
?

Common Questions About Diabetes Care

The things patients in Perth's northern suburbs ask us most
Q

Can a GP help manage diabetes?

Yes. A GP can help monitor your blood glucose, blood pressure, cholesterol, medications, kidney health and foot risk, review lifestyle factors, and refer you to other health professionals. Healthdirect lists a diabetes care team as potentially including a GP, endocrinologist, diabetes educator, dietitian and podiatrist.[14] Our GP team at Iluka can coordinate this care for you.

Q

What is a diabetes care plan with a GP?

In Australia, the older GP Management Plan and Team Care Arrangement system was replaced from 1 July 2025 by the GP Chronic Condition Management Plan (GPCCMP) framework. These plans help coordinate care for eligible patients with chronic or terminal medical conditions, including diabetes.[10][12]

Q

Can a diabetes care plan help with podiatry or dietitian visits?

Yes. Eligible patients with chronic conditions and complex care needs may be able to access Medicare benefits for some allied health services, such as podiatry and dietetics, under a GP Chronic Condition Management Plan or a multidisciplinary care plan.[10][11]

Q

Why is diabetic foot care important?

Diabetes can increase the risk of nerve and blood vessel damage in the feet, and regular podiatry checks can help identify that risk and prevent serious complications. Diabetes Australia notes that podiatrists can assess risk and help prevent foot damage.[12]

Q

How often will I need diabetes appointments, and are they bulk billed?

Most people see their GP every three to six months, with a full annual review of the eyes, feet, kidneys, blood pressure, cholesterol and heart risk. At Iluka Medical Centre, your care plan and one three-monthly review appointment are bulk billed Monday to Friday; weekend appointments are privately billed.[9][13]

The Bottom Line

A plan turns diabetes management into a system

People whose care follows a structured plan are more likely to hit their targets, and hitting those targets lowers the long-term risk of heart, kidney, eye and foot complications. Set up or review your diabetes care plan with the team at Iluka Medical Centre.

References

  1. 1 Blonde L, Umpierrez GE, Reddy SS, et al. AACE Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan — 2022 Update. Endocr Pract. 2022;28(10):923–1049.
  2. 2 Kalyani RR, Neumiller JJ, Maruthur NM, Wexler DJ. Diagnosis and Treatment of Type 2 Diabetes in Adults. JAMA. 2025;334(11):984–1002.
  3. 3 Peterson KA, Carlin C, Solberg LI, et al. Redesigning Primary Care to Improve Diabetes Outcomes (The UNITED Study). Diabetes Care. 2020;43(3):549–555.
  4. 4 Peterson KA, Carlin CS, Solberg LI, Normington J, Lock EF. Care Management Processes Important for High-Quality Diabetes Care. Diabetes Care. 2023;46(10):1762–1769.
  5. 5 American Diabetes Association Professional Practice Committee. Improving Care and Promoting Health in Populations: Standards of Care in Diabetes — 2026. Diabetes Care. 2026;49(Suppl 1):S13–S26.
  6. 6 Keng MJ, Tsiachristas A, Leal J, Gray A, Mihaylova B. Impact of achieving primary care targets in type 2 diabetes on health outcomes and healthcare costs. Diabetes Obes Metab. 2019;21(11):2405–2412.
  7. 7 American Diabetes Association Professional Practice Committee. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Care in Diabetes — 2028. Diabetes Care. 2028;49(Suppl 1):S61–S88.
  8. 8 Holt RIG, DeVries JH, Hess-Fischl A, et al. The Management of Type 1 Diabetes in Adults: A Consensus Report by the ADA and EASD. Diabetes Care. 2021;44(11):2589–2625.
  9. 9 Royal Australian College of General Practitioners. Management of type 2 diabetes: A handbook for general practice. RACGP, 2024.
  10. 10 Australian Government Department of Health and Aged Care. Changes to the MBS Chronic Disease Management Framework, effective 1 July 2025.
  11. 11 Services Australia. Services available under a GP chronic condition management plan, 2025.
  12. 12 Diabetes Australia. Changes to diabetes care plans in 2025; and Looking after your feet, 2025.
  13. 13 National Diabetes Services Scheme (NDSS). Your diabetes annual cycle of care. Fact sheet, June 2025.
  14. 14 Healthdirect Australia. Diabetes and your health care team. Australian Government, 2025.
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