Chronic Disease Management

SEMPHN aims to maximise the health and wellbeing of our community. We work with service providers to increase the efficiency and effectiveness of medical services for patients, particularly those at risk of poor health outcomes; and improve coordination of care to ensure patients receive the right care in the right place at the right time.

SEMPHN also offers tools and capacity building support chronic disease management across the catchment. 

It is estimated that about half a million people in South Eastern Melbourne live with one or more chronic health conditions. The incidence of chronic disease is unevenly spread across our catchment.


What is chronic disease management?

Chronic disease is an ongoing health condition or illness with persistent effects that can be controlled but not cured. Chronic disease often has significant, negative impact on the lives of individuals and their families.

Chronic disease management is the responsive, person centered planning and coordinating of health care for a patient that has one or multiple chronic diseases. The disease management for chronic conditions is undertaken by health professionals working in partnership with the patient. This can include monitoring, coaching motivation and educational support. This education aims to encourage the patient to take greater responsibility for their health through enhanced self-management behaviours. The health professional’s work together with the patient to support person centered goals. To achieve improvements in health related quality of life, coordination, consistency and continuity care is the aim of all chronic disease management. 


Practice Coaching to support chronic disease care

Practice Coaching is an online training tool developed by SEMPHN which empowers general practice to enhance frontline chronic disease care by building capacity in the following areas:

  • Chronic disease management
  • Health assessments
  • Health literacy, and
  • Disease prevention and early intervention.

Practices can gather ideas to streamline chronic disease processes, optimise workload distribution throughout the practice team and encourage a focus on patient-centred care, as per best practice principles.

Sign on here to Practice Coaching. For more information email  This email address is being protected from spambots. You need JavaScript enabled to view it..


Commissioning to support chronic disease care

Read about SEMPHN’s targeted chronic disease activities and funding opportunities.


Chronic Disease Service Mapping Project

SEMPHN is working with PwC and the Consumers Health Forum to take a close look at how the overall ‘system’ currently responds to the demand for chronic disease services (including prevention activities and patient management support), as well as identify service gaps and barriers to access.

The results will:

  • provide valuable information for you about where services are located, what types of services are provided, the staffing mix and referral pathways.
  • help design a model of chronic disease management that focuses on better service integration and patient experiences.
  • help shape future funding opportunities in chronic disease management.

For further information on the Chronic Disease Service Mapping Project contact Cathy Krishnan on 1300 331 981 or at This email address is being protected from spambots. You need JavaScript enabled to view it. .


Patient Centred Medical Home

A Patient Centred Medical Home combines the traditional core values of family medicine – providing comprehensive, coordinated, integrated, quality care – that is easily accessible and based on an ongoing relationship between a person and their health care team.

A medical home is a general practice which commits to being accountable for ongoing high-quality care for its patients. It provides care which is patient centred, accessible, comprehensive, and coordinated and has a focus on quality and safety.

Implementing the medical home model provides practices with the opportunity to implement refined ways of working within their practice and in their interactions with the broader health system. The model results in better chronic care management for patients.

Watch the Patient Centred Medical Home and Healthcare Neighbourhoods video.

Australia is formally trialling this model of care through Health Care Homes - this trial is empowering practices to make the necessary changes to practice workflows to wholly support this model of care for people with chronic and complex conditions. See SEMPHN’s Health Care Homes web page for more information.


Evidence-based care to support chronic disease care

Peak bodies develop evidence-based guidelines, and run programs and initiatives to help prevent chronic conditions and support people who have chronic conditions.

Here are links to some of the key ones relating to chronic disease:


Service Coordination Tool Templates (SCTT) to support chronic disease care

The Victorian Service Coordination Tools Templates (SCTT) assist health service providers to align practices, processes and systems. The SCTT was developed to assist with referrals to the Tertiary Public Health Management Centre.

The most efficient way to use the SCTTs is to incorporate them into your clinical software. The suite of SCTT forms are available here.

For further information on Service coordination in Victoria and the SCTTs go to Vic Health.


Empathetic general practice

Empathy is the ability to truly ‘step into someone else’s shoes’. What does empathy mean for general practice, especially when working with people who have chronic disease?

To embed empathy within your practice's routines, we've compiled information and practical examples around empathy in general practice that might help.


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Funding Opportunities

Tenders, Quotes & Expression of Interest Portal

If you’re interested in applying for funding opportunities, register your interest on SEMPHN's eProcure page. Once you register, you’ll receive information as it’s released.

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Contact Information

Need help?

For General Practice support, please call 1300 331 981 (option 2) or email providersupport@semphn.org.au

Looking for staff? A job?

Check-out our local primary health jobs page.

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