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 ‘at risk’ population groups.

At risk areas

Place-based	Diagnosis	Vulnerable groups
Frankston Dandenong Casey Cardinia	Iron deficiency COPD/asthma Heart disease Musculoskeletal conditions Kidney disease Cancer Diabetes Dementia	Refugees Homeless CALD Elderly (in Residential Aged Care Facilities) ATSI

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

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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 33 general practices across the 10 local government areas in the South Eastern Melbourne PHN catchment. The successful practices are:

General Practice	LGA
Airlie Womens Clinic (Prahran)	Stonnington
Alma Village Medical Centre	Glen Eira
Amberly Healthcare	Casey
Atticus Health	Frankston
Brighton General Practice	Bayside, Monash
Cabrini General Practice	Glen Eira
Chelsea Arcade Medical	Kingston
Doctors@Bayside	Bayside
Dr Peter Pereira	Greater Dandenong
Eastbound Clinic	Glen Eira
Emerald Medical Centre	Cardinia
First Health Medical Centre (Casey)	Casey
First Health Medical Centre (Hampton Park)	Casey
Glen Iris Medical Group	Stonnington
Headspace Frankston	Frankston
InterHealth Medical Clinic	Kingston
Lakeside Square Medical Center	Cardinia
Langmore Clinic	Casey
MyClinic Balclava	Port Phillip
MyClinic Elsternwick	Glen Eira
MyClinic Prahan	Stonnington
Pakenham Family Health	Cardinia
Peninsula Holistic General Practice	Mornington Peninsula
Rosebud Superclinic	Mornington Peninsula
Southland Medical Centre	Kingston
Springvale South Medical Centre	Kingston
St Kilda Medical Group	Port Phillip
Tanti Creek General Practice	Mornington Peninsula
The Langpark Medical Centre	Frankston
The Salvation Army	Port Phillip
Thompson Road Clinic	Casey
Total Care Medical Group	Frankston
Your Health Place	Glen Eira

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 were invited to apply, via Tenderlink, 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.

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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	LGA
The First Step Program in St Kilda	Culturally and Linguistically Diverse (CALD) Homelessness Refugees and Asylum Seekers	Port Phillip
Mackie Road Clinic in East Bentleigh	Over 65yo Culturally and Linguistically Diverse (CALD)	Glen Eira
Connect Health and Community (formally Bentleigh Bayside Community Health)	Over 65yo Culturally and Linguistically Diverse (CALD)	Glen Eria
Dandenong West Medical Centre in Dandenong	Over 65yo Culturally and Linguistically Diverse (CALD) Refugees and Asylum Seekers	Greater Dandenong
The Hastings Clinic in Hastings	Over 65yo Homelessness	Mornington Peninsula
High Street Medical Centre in Cranbourne	Over 65yo Culturally and Linguistically Diverse (CALD)	Casey
Stud Road Medical Centre in Dandenong	Over 65yo Culturally and Linguistically Diverse (CALD) Aboriginal and Torres Strait Islanders (ATSI)	Greater Dandenong
Wells Road Clinic in Chelsea Heights	Over 65yo Culturally and Linguistically Diverse (CALD)	Kingston

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 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. Following assessment, the panel reached consensus in relation to preferred provider. 

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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 commenced mid 2017. 

Organisation	Initiative Description
Peninsula Health	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 presenting to the Emergency Department (ED) by providing: outreach care coordination; medical consultancy; and nursing and allied health interventions. The funding grant will enable the program to operate from 9am – 9pm, 7 days per week.  This initiative also: supports effective discharge from ED; assists to redirect patients to primary health care providers; and enhances the hospital/ ED partnerships with Ambulance Victoria, General Practice and Residential Aged Care Facilities.
Monash Health	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.
Alfred Health	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: engaging a Diabetes Nurse Educator (DNE) to manage complex patients with type 2 diabetes; implementing education and support programs to patients to self-manage their condition, particularly in the AH period such as Diabetes Education and Self Management for Ongoing and Newly Diagnosed (DESMOND), diabetic nurse educator and dietician assessment, use of an exercise program via an Exercise Physiologist; and care coordination/case management to facilitate self-management for patients experiencing challenges due to complex health/social circumstances.

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.

More information

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  here.

For general information or queries about commisioning, 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