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.

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Chronic Disease Management

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