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Chronic Disease Management

We provide quick access to a range of information to support chronic disease management in the areas of: 

We recommend you read an Education Guide: Chronic disease, GP Management plans and team care and Chronic Disease Management - GP Services on the Department of Health website. 

The Australian Disease Management Association website also provides a collection of chronic disease management.

Diabetes

Respiratory/Asthma

Clinical Activities/Spirometry

Kidney Health

Palliative Care

NBMPHN is also working on an End of Life Care Project

Cardiovascular

Cancer

Practices can also participate in our Cancer Screening QI Program

Pain Management/Arthritis

Hepatitis

Shared Medical Appointments

Learn more about Shared Medical Appointments from the Australasian Society of Lifestyle Medicine.

Coordinated Veterans Care

The Coordinated Veterans' Care (CVC) Program is a team-based program designed to increase support for Gold Card holders with one or more targeted chronic conditions or complex care needs; and those who are at risk of unplanned hospitalisation. The CVC Program focuses on improving the management of chronic conditions and quality of life for eligible Gold Card holders who are most at risk of unplanned hospitalisation. Gold Card holders can include veterans, war widow/widowers and dependants. The CVC Program is aimed at Gold Card holders with the following chronic conditions:

  • congestive heart failure
  • coronary artery disease
  • pneumonia
  • chronic obstructive pulmonary disease
  • diabetes

GPs are paid to enrol Gold Card holders onto the CVC Program and to provide ongoing, comprehensive and coordinated care with the assistance of their practice nurse or a community nurse (from a DVA-contracted provider).

Hearing loss can have a significant impact on independence, participation in community life and the ability to communicate with others. Veterans with hearing loss can access services and support through a range of DVA programs, including the DVA Rehabilitation Appliances Program (RAP) and the DVA Tinnitus Program. Veterans can also access services through the Australian Government Hearing Services Program (the program) which is administered by the Department of Health.

DVA funds a comprehensive health assessment for anyone who has served a day in the Australian Defence Force (ADF). It's available to both permanent and reserve forces. The assessment is to help GPs identify and diagnose the early onset of physical and/or mental health problems among former serving ADF members.  Please see link below for screening tools.

https://at-ease.dva.gov.au/professionals/assessment-and-treatment/adf-post-discharge-gp-health-assessment

chronic disease management