Chronic Disease

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 vulnerable population groups.

At risk areas

Location	Diagnosis	Vulnerable groups
Frankston Dandenong Casey Cardinia	COPD/asthma Heart disease Musculoskeletal conditions Kidney disease Cancer Diabetes Dementia	Refugees Homeless Culturally and Liguistically Diverse (CALD) communities Elderly  Aboriginal and Torres Strait Islander people

See more information about chronic disease for general practice and health professionals.

Contact SEMPHN about chronic disease programs: Email This email address is being protected from spambots. You need JavaScript enabled to view it. or call 1300 331 981 (Option 4).

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After Hours

Managing a chronic disease can often mean people have needs outside of the general practice, and sometimes after the hours a practice is open. 

SEMPHN commissions activities to support people with chronic diseases to access the right care, in the right place at the right time. 

Read more about SEMPHN's commissioned After Hours services. 

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Chronic disease management services

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.

We work with service providers to increase the efficiency and effectiveness of medical services for patients and improve coordination of care to ensure patients receive the right care in the right place at the right time.

For more information on chronic disease management, click here. 

Care Coordination

Read more about SEMPHN's commissioned Care Coordination services.

Health Care Homes

Read more about SEMPHN’s commissioned Health Care Homes program. 

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Chronic disease prevention programs

Prevention activities play an important factor in keeping communities across south eastern Melbourne healthy. SEMPHN commissions prevention services and programs relating to cancer screening and Latent Tuberculosis. 

Cancer screening

Read more about SEMPHN's commissioned Cancer Screening services.

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Latent Tuberculosis (LTBI) community project

Latent Tuberculosis Infection (LTBI) is an asymptomatic condition that may progress to active tuberculosis (TB), sometimes decades after exposure. Southern Metropolitan Region has a quarter of all cases of Tuberculosis in Metro Melbourne (DHS 2020 data). In Victoria, it is known that approximately 90% of tuberculosis cases occur in those born overseas, and from reactivation of latent tuberculosis infection more than 3-5 years after arrival. Treatment of LTBI can reduce the risk of developing active disease. However, with the exception of contact tracing following local exposure to tuberculosis, only limited systematic testing or treatment programs for latent tuberculosis infection operate in Victoria at present. 

Victorian Tuberculosis Program (VTP)

SEMPHN has commissioned Melbourne Health to expand the existing model of care developed between the Victorian Tuberculosis Program (VTP). This program supports general practitioners and other health providers in the PHN catchment to develop knowledge and skills, to identify, screen and treat individuals with or at risk of Latent Tuberculosis Infection (LTBI). Program services include: 

• Provide VTP physician support for individual GPs (train and mentor)

• Supply medications to participating pharmacies

• Provide educational resources and materials for practices across the region, including new materials responding to advances in practice and impact of the COVID-19 pandemic

• Expand the existing GP community of practices amongst participating clinicians and teams 

• Develop a website home for community of practice and resources

Why is this project needed?

While TB is an uncommon disease in Victoria, it continues to have significant impact on affected individuals and families. In Victoria, an estimated 300,000 people have latent TB, and efforts to diagnose it and prevent active disease are critically important.

This project contributes to WHO’s End TB Strategy 2016 to 2035, with the implementation of the community-based practice model of care for Latent Tuberculosis Infection (LTBI), to allow increased numbers of people at risk to be screened and managed to prevent TB. 

For more information, refer to the VTP website

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Current and upcoming commissioning opportunities

You can register your interest for funding opportunities. You will receive updates about the tender process, including guidelines and timelines, when available.

To hear about future commissioning opportunities, subscribe to our commissioning newsletter, SEMaphore and register via eProcure.

For general information or queries about commissioning, email This email address is being protected from spambots. You need JavaScript enabled to view it.. 

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Associated tags

• chronic disease management
• commissioning