NSW Chronic Care Program

The key focus of the NSW Chronic Disease Program is Chronic Disease Management.

Chronic disease management (CDM) is a systematic, multilevel approach to improving health care for people with chronic disease across the continuum of care. The approach aims to prevent or delay the onset of chronic disease for individuals/population groups and reduce the progression and complications of those already diagnosed with one or more chronic diseases.

Principles which underpin the approach to chronic disease management include promoting person centred care with an active self management support approach where possible. This includes the development of a multidisciplinary shared care plan which is informed by a comprehensive health assessment and evidence-based treatment protocols.

Chronic disease rehabilitation is also an integral in the care of people with chronic disease including those who are at high risk of chronic disease, those newly diagnosed and those with significant and complex conditions. The core components of chronic disease rehabilitation include:

• Individualised goals setting
• Exercise to improve function, endurance and strength
• Education on topics such as disease process, disease management and modification of risk factors
• Nutritional advice
• Mechanisms to assess and address psycho-social support
• Supportive measures to promote self management in the long term

NSW Health works with Area Health Services and other partners such as GP NSW, the National Heart Foundation, Diabetes - NSW and Arthritis Foundation to support and develop models of chronic disease management.