What is Chr​​onic Disease?

Chronic diseases are medical conditions that tend to be long lasting and persistent in their symptoms or development. They include some cancers, heart disease, diabetes and chronic respiratory diseases.

Chronic diseases require ongoing management, yet most are preventable for many people through healthy lifestyle choices.

Chronic diseases impact on the physical, emotional and mental well-being of individuals, and may affect daily activities, relationships and employment. However, in many cases, health outcomes can be improved if conditions are managed well.

Program Purpose

The NSW Chronic Disease Management Program (CDMP) – Connecting Care in the Community - is a free service for people with chronic disease who have difficulty managing their condition and who are at risk of hospitalisation.

The CDMP provides care coordination and self-management support to help people with chronic disease to better manage their condition and access appropriate services in order to improve health outcomes, prevent complications and reduce the need for hospitalisation.

The CDMP connects the person and their carer with appropriate primary, community and acute care services by:

  • Proactively identifying people most in need of and likely to benefit from the program
  • Undertaking comprehensive assessment
  • Supporting shared care planning
  • Delivering care coordination and self-management support services
  • Regularly monitoring and reviewing participants

People in NSW aged over 16 years who have been in hospital or need more support to manage their needs are eligible for enrolment to the program. The target chronic diseases are Diabetes, Congestive Heart Failure, Coronary Heart Disease, Chronic Obstructive Pulmonary Disease and Hypertension, recognising that people with these diseases often have multi-morbidities such as depression, arthritis and dementia.​

The CDMP actively seeks to enrol and support people with complex needs who are at high risk of hospitalisation including Aboriginal people and frail elderly people. Other populations may also be prioritised for enrolment including people from culturally and linguistically diverse backgrounds, people with mental illness, people of low socio-economic status, people living in rural and remote locations and people living alone.

The Agency for Clinical Innovation (ACI) is leading the implementation of the CDMP on behalf of NSW Health.

Program Evaluation

In 2011, The George Institute was engaged to undertake an independent review of the Chronic Disease Management Program.

The State-wide Evaluation of the Chronic Disease Management Program [PDF] demonstrates the capacities developed by our public health system to better link community based and hospital services around the needs of the patient.

The evaluation has provided important insights for our implementation of our Integrated Care Program initiatives and will inform how we further develop effective models of care for people with chronic and complex conditions in NSW.

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Page Updated: Thursday 26 February 2015