Chronic conditions

Chronic conditions are the leading cause of illness, premature mortality and health system utilisation in the South Eastern NSW region. Improving care for people with chronic conditions can make a real difference to the long term health and wellbeing of local residents and communities.

Chronic conditions occur across the life cycle, becoming more prevalent with age. It is estimated that nearly 40 per cent of Australians aged 45 and over have two or more chronic diseases that compromise quality of life. Aboriginal people, people with a mental illness diagnosis and people with issues related to drug and/or alcohol misuse tend to be more at risk of developing chronic conditions.

Prevention is important in reducing the impact, complications and suffering caused by chronic conditions. Building consumer health literacy and awareness is fundamental in the prevention and management of chronic conditions; particularly among disadvantaged communities. End-of-life care must also be integrated into chronic conditions management.

Improving the prevention and management of chronic conditions

As the South Eastern NSW PHN, COORDINARE has an important role to play in improving coordinated and comprehensive care for the prevention and management of chronic conditions in the region.

Chronic conditions are a key priority area at COORDINARE. You can read our Health priority: Chronic conditions statement for more information. 

Working with general practice and primary care providers, COORDINARE aims to build more integrated models of care for consumers, increasing consumer capacity for self-management and prevention. 

St Vincent’s Chronic Pain Telehealth Outreach service is being offered to consumers in Southern NSW as part of a partnership between COORDINARE, Southern NSW Local Health District (LHD), the Agency for Clinical Innovation and St Vincent's Hospital Pain clinic. Click here to download the referral document for this service or see the flyer for details. 

More information on the St Vincent's Hospital Pain clinic can also be found on the ACT & Southern NSW HeathPathways portal

You can learn about one person's journey with the outreach service in the video below. 


Other commissioned programs:

  • COORDINARE in conjunction with the NSW Agency for Clinical Innovation (ACI) and Southern NSW Local Health District (SNSWLHD) are offering small group pain education and self-management programs commencing in early 2019 for patients suffering low to moderate chronic pain for more than 3 months. The programs will be delivered in Batemans Bay, Bermagui, Bega and Goulburn. For more details, see the flyer or contact Philippa Gately at  The Chronic Pain Management Program referral form can be found on the ACT & Southern NSW HealthPathways portal.
  • Programmed shared medical appointments: Australasian Society for Lifestyle Medicine (ASLM) – eight medical practices have been selected to offer shared medical appointments in weight control. A series of medical consultations in a supportive group setting where individuals can listen, interact, and learn. Milton Medical Centre will be the initial hub, with centres located in Wollongong, Merimbula, Cooma and North Nowra, with the addition of an Aboriginal Medical Service.
  • Rural and regional service gaps: Grand Pacific Health – offering a series of evidence-based physical activity and nutrition programs to fill an identified service gap to tackle the issue of overweight and obesity in the South Eastern NSW region.
  • Active8, Peer Coaching and Eat, Plant, Learn: Neami National – programs to address the poor physical health, particularly the high incidence of overweight and obesity, commonly experienced by people who have a mental illness.
  • Obesity service: Shoalhaven Family Medical Centres – offering a centralised obesity service for clients in the Shoalhaven region to access weight management, assessment and screening. It will also provide training opportunities by specialists in the field of weight loss and obesity to health providers to build knowledge and skills in obesity engagement in the local area.

Read more about the programs here.