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Chronic Disease Management


Objective: To focus on high priority groups to improve early identification and enhance access to services relating to chronic disease management to meet the needs of our local communities. This will be achieved through collaborations, pathways and partnerships with key stakeholders, commissioned initiatives and workforce education and training.


The Chronic Disease Management (CDM) program works to engage with GPs, AHPs, practice nurses and practice staff to enhance chronic disease management and optimise preventative health strategies.

The program offers support, training and assistance with:

  • MBS Primary Care items e.g. health assessments, care plans, asthma and diabetes service incentive payments
  • Best practice guidelines and clinical support systems
  • The use of screening tools e.g. diabetes risk assessment tool (AUSDRISK), cardiovascular risk calculator
  • Coordinating patient care e.g. referral pathways
  • Quality Improvement activities that utilise the Pen CAT data extraction tool e.g. Putting Data into Practice initiative 


Project officers are available to provide information, support and resources via practice visits, telephone/email and workshops.

Click here to read more about Care Plans

Click here for free access to TIS National interpreting service for GPs and NGOs

Click here to read more about practice management

Click here to access St George and Sutherland Hospitals CNC Contact Lists


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