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Far West Chronic Disease Prevention Group

Project Added:
21 September 2015
Last updated:
20 October 2015

Far West Chronic Disease Prevention Group


A monthly Chronic Disease Group (CDG) was established in Broken Hill, where clinicians tested participants for chronic disease risk factors and provided group education sessions that empowered participants to manage their own health.


To reduce acute exacerbations and premature progression of chronic illness in the Broken Hill community.


  • Improves coordination of chronic disease care for clients and clinicians.
  • Increases clients’ knowledge of chronic conditions.
  • Supports self-management of chronic conditions.
  • Delivers a unique referral pathway for clinicians, to allow for regular review of low-risk and priority clients.

Program status

Program dates

  • Start: March 2013
  • Finish: August 2015

Program status

Sustained - The program has been implemented, is sustained in standard business.


Chronic disease requires ongoing monitoring and guidance from a range of health professionals, which can often motivate clients to actively manage their own health if seen in a timely manner. However, providing regular consultations to chronic disease clients over the long-term can take up a significant amount of the clinicians’ time. This means that clients are often discharged from services once their acute issues have been resolved and may not be seen again until another acute episode occurs. The result is an increased rate of chronic conditions in the community as well as reduced self-management due to a lack of support.

Prior to the project, chronic disease clinicians in FWLHD carried out ad-hoc community testing of risk factors, usually at community events. These events were well attended by FWLHD staff and community members, with participant feedback suggesting they were useful in making them aware of chronic disease risks.

However, this model didn’t allow for follow-up of abnormal results or tracking the progress of the disease. It also didn’t allow for clinicians to formally register interventions or interactions as occasions of service, which meant that the time spent on these activities could not be used to generate income for the health service under the Activity Based Funding (ABF) system.


  • A monthly drop-in clinic was established in the Allied Health Department of Broken Hill Base Hospital and open to the entire community for one hour each month.
  • Documentation was developed including doctor letter templates, client data sheets and alphabetised client folders.
  • The clinic was promoted to local media, General Practitioners (GPs) and chronic disease clinicians in FWLHD. Brochures were also sent to people who attended the Emergency Department for an exacerbation or issue related to chronic disease, such as diabetes and heart disease.
  • The clinic was staffed by chronic disease clinicians, who measured each participant’s weight, Body Mass Index (BMI) blood pressure (BP) and blood glucose levels.
  • Participants were provided with education and interventions as required or indicated by their test results.
  • Test results were sent to the participant’s GP after each clinic session, to ensure continuity of care.
  • A group education session was held each month on a range of topics relevant to chronic disease management and prevention, to support self-management and care.

Implementation sites

Broken Hill Base Hospital, FWLHD.


The clinic saw an average of seven participants per month, with some people visiting every month and others attending every 2-3 months to just ‘check-in’. These results are from the initial 12-month pilot project, however the group continues to run on a monthly basis.

Data collected from participants who attended at least three clinics during the pilot project showed the following improvements:

  • average weight loss of 2.7kg
  • average BMI reduction of 0.81 kg/m2
  • systolic BP reduced by 4.6mm Hg
  • diastolic BP reduced by 6.2mm Hg.

These outcomes are important results for those with or at risk of chronic disease. While some changes are small, they are still a positive step for disease management. The reduction in blood pressure is significant and in the long term may result in a reduced cardiovascular disease risk.

Results of a feedback survey provided to six participants in May 2015 showed that 100% of attendees agree or strongly agree with the statement: ‘Attending the Chronic Disease Group has helped me manage my own health’. This achieved the desired outcome of the project: up-skilling clients to ensure they feel capable of controlling and managing their own health.

The CDG also improved time management for clinicians. It allowed clinicians to review 10 clients per hour in a group setting, instead of two per hour in individual consultations.

Lessons learnt

  • The importance of pre-planning was highlighted in this project. Prior to opening the clinic, all of the required documents were prepared and ready to use, which made implementation a smooth process.
  • Ongoing, regular promotion is important. After our initial wave of recruitment, we lagged in new numbers and required further promotion. New recruitment is again lagging due to reduced promotion. We are currently investigating avenues for regular promotion in local media, to coincide with the monthly clinic.
  • Our overarching, big-picture learning from this clinic has been that rapport builds trust, trust improves confidence and confidence promotes compliance. The rapport we build with clients by seeing them on a regular basis helps us gain their trust, which means they respect our expertise and follow our advice more readily.


Heidi Drenkhahn
Community Dietitian,
Far West Local Health District
Phone: 08 8080 1397

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