Chronic Disease Management Service
The core business of the Chronic Disease Management (CDM) service is to work collaboratively across all sectors of health care to provide the right care at the right time at the right place for patients with a diagnosed chronic condition. CDM in NSW is now under the banner of Integrated Care. The service will focus on greater links with patients and General Practice and short term intervention for patients with chronic and complex needs.
CDM Service Aims:
- Using a range of strategies to enable comprehensive and coordinated care for people with chronic conditions across all health settings (this may include care navigation, health coaching, care coordination and case management).
- Encourage and support an individual’s capacity to engage in health behaviours and implement appropriate self-management strategies.
- Work in partnership with General Practice and other health care providers under the Patient Centred Medical Home model.
- Establish and maintain collaborative relationships with service providers to ensure continual and consistent continuity of care.
- Minimise the potential for unplanned hospital admissions and Emergency Department (ED) presentations.
- Throughout the management intervention phase, monitor and regularly review patients and carers regarding clinical and non-clinical health needs.
- Connect and support patients and their carers to better manage and maintain their optimal health status.
- Facilitate the principles of ‘safe clinical handover’ by fostering effective and appropriate communication between relevant health care providers.
- Provide Chronic Disease Education and/or awareness programs to clinicians and/or the wider community.
CDM Patient Criteria Requires a Patient to:
- Be identified as requiring chronic and/or complex care support
- Be over the age of 16
- Reside in the NNSWLHD footprint
- Have one or more of the following:
- Chronic condition/s which have required hospitalization in the past 12 months or;
- a risk of hospitalisation within the next 15 months
- Identified carer stress issue
- Would benefit from interventions to address chronic disease risk factors and self-management support in order to attain goal/s
Interventions may include:
- Self-management/Health coaching
- Care navigation/ Non-clinical coordination
- Case management/Clinical coordination
- Acute to primary transfer of care
Following an evaluation of the former Chronic Disease Management Program (CDMP) the NSW Ministry of Health has undertaken a redesign process to align the elements of the CDMP with Integrated Care. The redesigned model strengthens the emphasis on:
- Selecting the right people and matching them to the right intervention;
- The importance of engaging patients and carers and collecting Patient Reported Measures;
- The need for collaborative relationships with the Primary Health Networks (PHNs) and General Practitioners (GPs), and supporting capacity and capability building in primary care; and
- The need for technology to support shared care planning, information sharing and data collection. (Draft document from MoH - Integrated Care for People with Chronic Conditions-May 2016).
- The development, implementation and review of functional/treatment goals in partnership with the client.
CDM operates Monday – Friday
With key staff members linked to Tweed, Byron, Murwillumbah, Lismore, Ballina, Casino, Grafton and Maclean Hospitals.
Referrals can be made by phone:
1300 361 465
Or by email:
Richmond Valley area:
Clarence Valley area:
Tweed Heads area: