Chronic Disease Management Support

Managing a complex or long-term health condition requires structured clinical oversight, proactive tracking, and continuous support to maintain your quality of life and prevent unmanaged health deterioration.

At Makhills Health, we deliver comprehensive Chronic Disease Management Support throughout Greater Perth. Managed and executed by experienced Registered Nurses, our clinical care team provides tailored condition monitoring, symptom control, and individualised support plans aligned with your NDIS goals and healthcare requirements.

4-Step Chronic Disease Care Framework

To maintain clinical oversight, promote early intervention, and comply with NDIS Quality and Safeguards standards, Makhills Health follows a structured care protocol

In-Home Initial RN Assessment:

A Registered Nurse performs a complete health intake, physical cheque, and baseline vital measurements tailored to your health requirements.

Tailored Monitoring Plan

We formulate an individualised tracking schedule outlining monitoring frequencies, baseline targets, and escalation triggers.

Routine Clinical Data Logging

Qualified nurses conduct regular visits to measure vitals, cheque skin integrity, track blood glucose or key metrics, and document health trends.

GP Liaison & Care Plan Review

Ongoing sharing of health data with your treating doctor and periodic care plan updates to optimise your health outcomes.

Comprehensive Chronic Disease Management Services We Provide

We offer a broad range of clinical support and long-term health management services tailored to your NDIS Community Nursing plan:

Management AreaSpecialised Care Provided
Diabetes & Metabolic SupportRoutine blood glucose tracking, ketone checks, sliding scale insulin oversight, and diabetic care education.
Cardiovascular Care MonitoringBlood pressure tracking, fluid management, pulse assessment, and heart condition symptom oversight.
Respiratory Condition OversightOxygen saturation monitoring, nebulizer support, inhaler technique reviews, and COPD/asthma action plan management.
Neurological Condition ManagementOngoing symptom tracking, mobility support coordination, and clinical oversight for progressive conditions.
Medication Adherence & ReviewStructured assistance with complex medication schedules, dosage reviews, and side-effect monitoring.
Symptom & Escalation TrackingContinuous logging of condition-specific changes to identify early warning signs and prevent crises.



Why Choose Makhills Health 

  • Registered Nurse Leadership: All care strategies, monitoring schedules, and clinical routines are managed and supervised directly by qualified Registered Nurses.

  • NDIS Community Nursing Coverage: Access long-term condition management funded under NDIS Community Nursing and High Intensity support categories.

  • Early Deterioration Detection: Systematic tracking helps detect subtle physical changes early, significantly reducing emergency room visits and hospital admissions.

  • Integrated Care Coordination: Seamless collaboration and regular reporting with your GP, medical specialists, and NDIS support team.

Frequently Asked Questions

Is chronic disease management support funded by my NDIS plan?

Yes. Clinical monitoring, symptom management, and nursing support for long-term health conditions fall under NDIS Community Nursing and High Intensity Daily Personal Activities when linked to your disability requirements.

Visit frequencies are tailored to your specific clinical requirements—ranging from daily nursing checks for unstable conditions to weekly or monthly clinical reviews.

Ready to Get Started

Speak directly with our Perth care team to discuss your goals, arrange a free consultation, or submit a fast-track NDIS referral.