Chronic conditions

Chronic disease is the leading cause of illness, disability and death in Australia and it is estimated that up to 50 per cent of patients visiting a GP each year have one or more chronic conditions (Bettering the Evaluation and Care of Health Study 2014 [BEACH]).

That figure is likely to rise, with almost 28 per cent of Australians now meeting the definition of obesity - up from 10 per cent in 1975. In fact, according to a new report published recently in The Lancet, it is estimated that more than a third of Australians will be obese by 2025.

This is certainly a serious health matter. People with chronic conditions may have complex health needs requiring multidisciplinary and team-based care.

Models of care in general practice

The Commonwealth recently released its Primary Health Care Advisory Group’s (PHACG) options discussion paper: Better outcomes for people with chronic and complex health conditions through primary health care.

This discussion paper considers possible reform options which will inform the government’s development of a healthier Medicare to support people with complex and chronic diseases and keep them out of hospital longer. See Minister Ley’s media release.

The Federal Government's Healthier Medicare package is a step in the right direction to improving the way we care for Australians with chronic and complex conditions, and will hopefully keep more out of hospital and living happier and healthier lives at home. Details of how this will be fully implemented are yet to be released and we will certainly let you know as more information comes to light.

COORDINARE - South Eastern NSW PHN will support practices to enhance their chronic disease prevention and management by providing education to promote best practice, helping them use data to improve quality, supporting them to uptake systems to improve communication and care coordination (such as eHealth) and involving them in local initiatives that ensure patients receive the right care in the right place at the right time, such as HealthPathways.

For chronic disease management templates and resources, or to read more about the Patient Centred Medical Home visit our Resource library.

If you would like to discuss further how we might work with your organisation to improve chronic disease management please contact or call 1300 069 002. 

Local chronic disease management services

From 1 July 2015, Grand Pacific Health will be undertaking the delivery of chronic disease management services previously provided by the two former Medicare Locals in the region - Illawarra Shoalhaven Medicare Local and Southern NSW Medicare Local.

This follows an agreement made by COORDINARE - South Eastern NSW PHN and Grand Pacific Health, enabling important primary care services to continue to be offered in the region with minimal disruption to clients.

For more information about chronic disease management services offered or for details on how to refer patients to Grand Pacific Health please go to or phone 4220 7600.

The Get Healthy Service offers participants free and confidential telephone-based expert advice. Their health coaches will support participants to make lifestyle changes regarding:

  • healthy eating
  • physical activity
  • achieving and maintaining a healthy weight

Through regular contact, advice and coaching, participants can achieve a healthier, more physically active lifestyle.

To refer a patient into the Get Healthy Service, simply complete the referral form and either email or fax it back to the service (contact details on the form).

For more information go to Get Healthy NSW or phone 1300 806 258, or email

Managing diabetes in an emergency

New research conducted by Diabetes Australia (DA) and the Australian Diabetes Educators Association (ADEA) suggests that people with diabetes need more relevant information to equip them to manage their condition during and after an emergency.

The new resources are profiled in a stakeholder action kit, which was jointly developed by DA and ADEA to provide emergency preparedness information for organisations that help people with diabetes.

The Diabetes Emergency Plan, available for download here, is a leaflet containing important information that will help your patients keep managing their diabetes during a natural disaster or emergency.

The Plan lists their medical details and important contacts and has a checklist for preparing a Diabetes Emergency Kit.

Managing Your Diabetes in an Emergency is a companion flyer available for download here that explains how to use the Plan and how it can help people self-manage their diabetes in an emergency.