The Chronic Disease Management (formerly Enhanced Primary Care - EPC).

General Practitioner services under the Medicare Benefits Schedule (MBS) enable GP's to plan and coordinate the health care of patients with chronic or terminal medical conditions, including patients with these conditions who require multidisciplinary, team-based care from a GP and at least two other health or care providers. 

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.