Chronic Disease and Post-Acute Care
Chronic diseases are the leading cause of illness, disability and death in Australia. With changing lifestyles and ageing population, chronic diseases have become increasingly common and now cause most of the burden of ill health.
Based on available data, the table below indicates some of the key priority areas in the South Eastern Melbourne catchment. This includes prevalent chronic diseases in the region, identified local government areas with higher-than-average chronic disease rates, and ‘at risk’ population groups.
At risk areas
In order to commission chronic disease services that meet the needs of the catchment, SEMPHN will work with the sector to co-design models of care that have the potential to reduce potentially preventable hospitalisations and support the management of people with chronic conditions in a primary care setting. This will result in better health outcomes for patients, including models of care that have a focus on:
- Care coordination and continuity of care
- Service integration between primary, secondary and tertiary/acute services
- Post-acute care (i.e. discharge planning)
SEMPHN continues to engage with a range of stakeholders across the sector to support this approach and encourage innovation and partnerships to address chronic disease in our community.
You can register your interest for funding opportunities. You will receive updates about the tender process, including guidelines and timelines, when available.
See more information about chronic disease for General Practice and health professionals.
Information session for General Practice: building capacity to support care coordination for chronic and complex conditions.
On 12 April 2017 in Doveton, a tender information session was held that covered an overview of the grants on offer, an outline of the application process, including response expectations, and an opportunity for questions and answers.
A recording of the question and answer section of the session can be viewed here.
A question and answer document from the session can be found on Tenderlink.
A sample budget can be viewed here. It can be used as a guide to help practices establish their own budget as part of the application. The total budget requested should be included in the final (free text) question.
The closing date for requests for further information via the Tenderlink forum, is 20 April, 2017.
Commissioning opportunities awarded
Building capacity to support care coordination for chronic and complex conditions
A total of $3 million in grants has been awarded to 34 general practices across the 10 local government areas in the South Eastern Melbourne PHN catchment.
The successful practices are:
Airlie Womens Clinic Pty Ltd (Prahran)
|Emerald Medical Centre Pty Ltd||Cardinia|
|Sonic Clinical Services Pty Ltd||Port Phillip|
|Atticus Health Pty Ltd||Frankston|
|Southland Medical Centre||Kingston|
|First Health Medical Centre||Casey|
|Junin Pty Ltd ATF The Langpark Medical Centre||Frankston|
|GPR Australia Pty Ltd||Mornington Peninsula|
|Distinct Health Care Clinic||Greater Dandenong|
|The Salvation Army||Port Phillip|
|Boldly Going Pty Ltd & S. P. Kaye & K. S. Reid & others T/as D&C Partners||Kingston|
|Eastbound Clinic||Glen Eira|
|Springvale South Medical Centre||Kingston|
|headspace Frankston (YSAS Pty Ltd)||Frankston|
|The Trustee for Health and Education Trust||Glen Eira|
|Thompson Road Clinic||Casey|
|S.E Mc Donald||Cardinia|
|MyClinic Elsternwick||Glen Eira|
|First Health Medical Centre (Casey) GP Pty Ltd||Casey|
|Healy Lazarovits Prichard & Taft Partnership||Stonnington|
|Pakenham Family Health||Cardinia|
|Total Care Medical Group||Frankston|
|MyClinic Balclava||Port Phillip|
|St Kilda Medical Group||Port Phillip|
|Peninsula Holistic GP||Mornington Peninsula|
|Cabrini Health Limited||Glen Eira|
|Becmor Pty Ltd - T/A Amberly Healthcare||Casey|
|Sri Bros Pty Ltd||Kingston|
|AVMC Holdings Pty Ltd ATF Alma Village Medical Centre Unit Trust||Glen Eira|
|Link Health and Community||Bayside, Monash|
|MPGn&J PEREIRA PTY LTD||Greater Dandenong|
The grants will build each practice’s capacity to manage patients with chronic and complex conditions and help reduce potentially preventable hospitalisations – one of the key PHN national priorities.
System-wide change is expected to result from the grant-funded activities which will run from June 2017 to June 2018. Specifically, the objectives are to:
- improve the health system, service and health literacy of patients and their families
- enhance patients’ ability to manage their own health needs through self-care strategies
- improve health outcomes for those patients with poorly managed chronic conditions
- reduce the rate of potentially preventable hospitalisations for chronic conditions in the SEMPHN region
- increase the efficacy of care coordination strategies to better manage chronic and complex conditions and to improve the patient’s quality of life, and
- improve the sustainability of the practice by improving systems and quality to accommodate more clients and offer additional billable services.
The Commissioning Process
An open tender process was used for the commissioning of services to build capacity to support care coordination for chronic and complex conditions.
Applicants who registered via Tenderlink were invited to apply by responding to a series of questions, which were assessed against a set evaluation criteria by an assessment panel. The panel reached consensus in relation to the successful applications.
Improving health outcomes for priority populations groups with complex and chronic conditions
In April 2017, eight health care providers received funding to deliver a suite of initiatives to improve health outcomes for priority population groups with complex and chronic conditions within the South Eastern Melbourne PHN region. The successful applicants are:
|Provider||Priority focus groups|
The First Step Program in St Kilda
|Mackie Road Clinic in East Bentleigh||
|Connect Health and Community (formally Bentleigh Bayside Community Health)||
|Dandenong West Medical Centre in Dandenong||
|The Hastings Clinic in Hastings||
|High Street Medical Centre in Cranbourne||
|Stud Road Medical Centre in Dandenong||
|Wells Road Clinic in Chelsea Heights||
Each provider will deliver the following initiatives to at least 100 patients between June 2017 and June 2018:
- improve access for at risk population groups to primary care services for the management of their complex and chronic conditions
- improve health outcomes for patients with poorly managed chronic conditions
- reduce the rate of Potentially Preventable Hospitalisations (PPH) for chronic conditions in the SEMPHN region, and
- increase the efficacy of care coordination strategies to better manage chronic and complex conditions, and improve quality of life.
The Commissioning Process
An open tender process was used for the commissioning of services to improve outcomes for priority populations groups with complex and chronic conditions. Applicants registered via Tenderlink were invited to apply by responding to a series of questions, which were assessed against a set evaluation criteria by an Assessment Panel. Following assessment, the panel reached consensus in relation to the preferred provider.
Creating better links to primary care through community health services
In April 2017, Peninsula Health, Monash Health and Alfred Health were successful in receiving funding to create better links to primary care through their publicly-funded auspiced community health services. The total funding allocated was around $600,000 and the initiatives will run from approximately May 2017-18.
Peninsula Health Community Care After Hours Care Diversion Project
This project extends the current Community Care program, which aims to support patients that frequently utilise hospital and/or at risk of
The funding grant will enable the program to operate from 9am – 9pm, 7 days per week.
This initiative also:
Redesign Of Residential In Reach (RIR) After-Hours Model
Nursing staff will be based at Dandenong Hospital ED between the hours of 9pm and 8:30am daily, supporting ED staff to facilitate appropriate transition and discharge of residents back to residential aged care facilities.
Better Integrated Care for Type 2 Diabetes
Using integrated care pathways, patient education and support mechanisms, this model of care is aimed at optimising the ability of patients with Type 2 diabetes to self-manage their condition in the community particularly in the After Hours (AH) period by:
The commissioning process
Invitations were sent to auspiced Community Health Services (CHS) within the SEMPHN catchment as they are large providers of primary care, and have experience in delivering a multitude of preventable strategies. Each organisation submitted a proposal that was carefully assessed and considered by a panel comprising internal and external representatives. All three organisations were successful in their submission.
Events and Education See all
We acknowledge the Kulin Nation who are the traditional custodians of the land our catchment covers. We pay our respects to them, their culture and their Elders past, present and future, and uphold their relationship to this land.
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