Around half a million people in south east Melbourne live with one or more chronic health conditions. In south east Melbourne, Frankston, Dandenong, Casey and Cardinia have higher-than-average chronic disease rates. The most prevalent chronic diseases in our region are: chronic obstructive pulmonary disease, asthma, heart disease, musculoskeletal conditions, kidney disease, cancer, diabetes and dementia.

SEMPHN partners to make quality care more accessible and integrated, and easier to navigate – especially for people who need it most. We offer tools and other support for chronic disease management and we commission care coordination programs and prevention services for cancer screening and Latent Tuberculosis. 

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 a significant, negative impact on the lives of individuals and their families.

Chronic disease management is the responsive, person-centred planning and coordinating of health care for people who have one or more chronic diseases. It is undertaken by health professionals in partnership with the person. This can include monitoring, coaching, motivation and educational support. Education aims to encourage people to take greater responsibility for their health through certain behaviours, like doing regular exercise.

Health professionals work together with people to support goals that are important to them. Coordination, consistency and continuity of care is the aim of all chronic disease management. This is what helps to achieve improvements in health-related quality of life.