Chronic Care Network Resources

These resources relate to improving care for people with pre-existing or long term illness, including Chronic Obstructive Pulmonary Disease and Hypertension, recognising that people with these diseases often have multimorbidities such as depression, arthritis and dementia.

Chronic Care Network Newsletters

Newsletters from the Chronic Care Network

https://aci.health.nsw.gov.au/networks/chronic-care/newsletters

Format: Webpage

Subcategory: Other Resource Type: Newsletters

Updated: 6 January 2016

Frailty Forum

https://aci.health.nsw.gov.au/resources/chronic-care/other/frailty-forum

Format: Webpage

Subcategory: Other Resource Type: Other

Updated: 4 March 2020

Australian Disease Management Association

http://www.adma.org.au/

Format: Webpage

Subcategory: Organisations Resource Type: External Links

Updated: 16 November 2020

Health Change Australia

http://www.healthchange.com/

Format: Webpage

Subcategory: Organisations Resource Type: External Links

Updated: 16 November 2020

ACI Integrated Care

The Agency for Clinical Innovation (ACI) has been commissioned to lead the implementation of two streams of the NSW Integrated Care Strategy - Risk Stratification and Patient Reported Outcomes/Experience Measures.

https://aci.health.nsw.gov.au/resources/chronic-care/aci/integrated-care

Format: Webpage

Subcategory: ACI Integrated Care Resource Type: Web Resources

Updated: 29 October 2015

Risk Stratification Program

Risk stratification approaches support a focus on organising care to meet the needs of targeted patients and their carers, rather than organising services around provider structures. Early identification and selection of people at risk of poorer patient health outcomes will enable the provision of appropriate integrated care interventions and mitigation strategies.

https://aci.health.nsw.gov.au/resources/chronic-care/aci/risk-stratification-program

Format: Webpage

Subcategory: ACI Integrated Care Resource Type: Web Resources

Updated: 29 October 2015

Care pathways for people with neurodegenerative and neuromuscular conditions: Action areas for consideration by ACI Networks

This Action areas for consideration by ACI Networks document aims to support ACI Networks to deliver and/or enhance current and developing models of care to improve outcomes for people with neurodegenerative and neuromuscular conditions. It should be read in conjunction with the Diagnostic report.

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0019/332281/neuro-action-areas.pdf

Format: PDF File (2.7 MB) Alternate Content: --

Subcategory: Care pathways for people with neurodegenerative and neuromuscular conditions Resource Type: Reports

Updated: 6 October 2016

Care pathways for people with neurodegenerative and neuromuscular conditions: Summary report - diagnostic exercise

This Diagnostic report draws together information about care and service issues for people affected by neurodegenerative (ND) and neuromuscular (NM) conditions in NSW.

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0020/332282/Neuro-diagnostic-report.pdf

Format: PDF File (648.2 KB) Alternate Content: --

Subcategory: Care pathways for people with neurodegenerative and neuromuscular conditions Resource Type: Reports

Updated: 6 December 2017

Participant experience focus groups

https://aci.health.nsw.gov.au/resources/chronic-care/participant-experience-focus-groups/participant-experience-focus-groups

Format: Webpage

Subcategory: Participant experience focus groups Resource Type: Clinician Summaries

Updated: 21 October 2016

Participant experience focus groups: facilitation guide

This guide shows how LHDs and PHNs can use focus groups to collect information about the participant experience with the ultimate aim of improving services.

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0006/333861/Participant-experience-focus-group-guide.pdf

Format: PDF File (612.3 KB) Alternate Content: --

Subcategory: Participant experience focus groups Resource Type: Implementation Guides

Updated: 28 September 2016

Chronic care stories

This collection of patient story videos highlights the importance of self-management and coordinated care to support people living with chronic conditions.

https://aci.health.nsw.gov.au/resources/patient-experience/stories/stories

Format: Webpage

Subcategory: Patient stories Resource Type: Web Resources

Updated: 12 January 2017

Social determinants of health

Presentation on the social determinants of health initiatives by the Chronic Care Network

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0006/347622/Franca_Facci_Social_Determinants.pdf

Format: PDF File (1.2 MB) Alternate Content: --

Subcategory: Social determinants of health Resource Type: Presentations

Updated: 6 February 2017

Your health - Harry Burns

Harry Burns presented on the importance of early years and the impact of social determinants on a community’s health

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0009/348138/Harry-Burns-scoial_-determinants.pdf

Format: PDF File (5.8 MB) Alternate Content: --

Subcategory: Social determinants of health Resource Type: Presentations

Updated: 10 February 2017

Health inequalities - Ruth Hussey

Ruth Hussey presentation on improving healthcare, especially improving outcomes and addressing the role that poverty can play in creating ill health.

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0010/348139/Ruth_Hussey-social-determinants.pdf

Format: PDF File (1.0 MB) Alternate Content: --

Subcategory: Social determinants of health Resource Type: Presentations

Updated: 10 February 2017

Social Determinants of Health

https://aci.health.nsw.gov.au/resources/chronic-care/social-determinants-of-health/sdoh

Format: Webpage

Subcategory: Social determinants of health Resource Type: Other

Updated: 19 November 2018

Rehabilitation for chronic conditions framework

Rehabilitation for Chronic Conditions Framework

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0006/385998/ACI_Rehabilitation_for_-chronic_conditions_framework_FINAL.PDF

Format: PDF File (1.7 MB) Alternate Content: --

Subcategory: Rehabilitation for chronic conditions framework Resource Type: Frameworks

Updated: 24 October 2017

Rehabilitation for chronic conditions framework - Information summary

A snapshot summary of the Rehabilitation for chronic conditions Framework.

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0006/386196/Information-sheet-Poster.pdf

Format: PDF File (112.0 KB) Alternate Content: --

Subcategory: Rehabilitation for chronic conditions framework Resource Type: Posters

Updated: 13 October 2017

Rehabilitation-cc-framework.jpg

https://aci.health.nsw.gov.au/__data/assets/image/0003/396192/Rehabilitation-cc-framework.jpg

Format: Image (127.3 KB) Alternate Content: --

Subcategory: Rehabilitation for chronic conditions framework Resource Type: Other

Updated: 16 November 2020

Rehabilitation for chronic conditions - Flow diagram

A diagram identifying the core components for chronic conditions rehabilitation and their linkages.

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0011/386192/Rehabilitation-for-chronic-conditions-Flow-diagram.pdf

Format: PDF File (101.8 KB) Alternate Content: --

Subcategory: Rehabilitation for chronic conditions framework Resource Type: Other

Updated: 29 September 2017

Rehabilitation (for chronic conditions) - Plan template

An optional Rehabilitation for Chronic Conditions Framework resource that may be adapted to suit individual services or programs.

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0010/386182/Rehabilitation-plan-template.pdf

Format: PDF File (45.9 KB) Alternate Content: --

Subcategory: Rehabilitation for chronic conditions framework Resource Type: Template

Updated: 29 September 2017

Lymphoedema: A guide for clinical services

Lymphoedema is a chronic swelling of a limb or body region and is associated with significant morbidity, loss of function and, on rare occasions, mortality. Poor management of lymphoedema can have detrimental effects on a person’s physical and psychosocial health. Pain and discomfort are frequent symptoms, and people with lymphoedema have increased susceptibility to acute cellulitis, requiring hospitalisation and antibiotic therapy.

https://aci.health.nsw.gov.au/resources/chronic-care/lymphoedema/lymphoedema-guide

Format: Webpage

Subcategory: Lymphoedema Resource Type: Clinical Guidelines

Updated: 28 February 2019

NSW Integrated Care in NSW

The previous Chronic Disease Management Program has been aligned with the NSW Integrated Care Strategy. The new model, Integrated Care for Patients with Chronic Conditions reflects Commonwealth reforms and supports equitable access, comprehensive evaluation and local flexibility to ensure the needs of individual patients can be met.

https://www.health.nsw.gov.au/integratedcare/Pages/default.aspx

Format: Webpage

Subcategory: Integrated Care for People with Chronic Conditions Resource Type: Web Resources

Updated: 16 November 2020

Chronic Care Network

Contact

Jenny Caspersonn
Manager, Chronic Care Network

+61 2 9464 4682

jenny.caspersonn@health.nsw.gov.au