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 to support chronic disease management.
What is chronic disease management?
Chronic disease is a long-lasting health condition or illness that can be controlled but not cured. Chronic disease often has significant, negative impacts on the lives of individuals and their families.
In our region, the incidence of chronic disease is unevenly spread across our catchment.
Primary health providers face a range of challenges including communication, information-sharing and coordination of care across health providers.
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 are able 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.
Commissioning to support chronic disease care
Health Care Homes
Health Care Homes is a Commonwealth Government initiative to improve the provision of care for people with chronic and complex conditions. SEMPHN is one of 10 Primary Health Networks selected for Phase One of Health Care Homes.
Under this model, eligible patients will voluntarily enrol with a participating medical practice known as their Health Care Home. Participating practices will provide a patient with a ‘home base’ for the ongoing coordination, management and support of their conditions.
General practices and Aboriginal Community Controlled Health Services (ACCHS) have submitted applications and selection by the Department of Health is currently underway.
For more information about Health Care Homes, visit the Department of Health’s Health Care Home FAQ.
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.
Effective Service Coordination means:
- A person centred approach to service delivery
- Consumers receive a seamless and integrated response
- People have their health and social needs identified early, preventing deterioration in health.
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.
Read about Nellie, an SMS-based system to promote patient self-care.
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:
- Alcohol and other Drugs
- Australasian Society of Clinical Immunology and Allergy
- Arthritis Australia
- Australian Kidney Foundation
- Baker IDI – Heart & Diabetes institute
- Beyond Blue – mental health
- Black dog Institute – depression support
- Cancer Council Australia
- Continence Australia
- Deafness Forum of Australia
- Diabetes Australia
- Health Direct
- Lung Foundation Australia
- Melbourne Sexual Health Centre
- National Asthma Council
- National Heart Foundation
- National Stroke Foundation
- Nutrition Australia
- Osteoporosis Australia
- Palliative Care Australia
- Pain Australia
- Quitline – smoking cessation
- Vision Australia
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.
While the Australian Government Department of Health has contributed to the funding of this website, the information on this website does not necessarily reflect the views of the Australian Government and is not advice that is provided, or information that is endorsed, by the Australian Government. The Australian Government is not responsible in negligence or otherwise for any injury, loss or damage however arising from the use of or reliance on the information provided on this website.