Chronic Care 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

Added: 26 August 2014 Updated: 6 January 2016

Australian Disease Management Association

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

Format: Webpage

Subcategory: Organisations Resource Type: External Links

Added: 9 July 2014 Updated: 25 July 2014

Health Change Australia

http://www.healthchange.com/

Format: Webpage

Subcategory: Organisations Resource Type: External Links

Added: 9 July 2014 Updated: 25 July 2014

Healthways Australia

http://www.healthwaysaustralia.com.au/

Format: Webpage

Subcategory: Organisations Resource Type: External Links

Added: 9 July 2014 Updated: 25 July 2014

NSW Chronic Disease Management Program – Connecting Care in the Community: Service Model 2013

The Service Model describes the core elements and principles that underpin the Chronic Disease Management Program (CDMP). It aims to support the implementation and the ongoing development of the Program.

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0016/201832/ACI13-011-CDMP-services-web.pdf

Format: PDF File (768.3 KB) Alternate Content: --

Subcategory: Chronic Disease Management Program Resource Type: Frameworks

Added: 28 October 2013 Updated: 20 August 2015

Chronic Disease Management Program Self-Assessment: Quality Improvement Process

An overview of the process to use the Chronic Disease Management Program Self Assessment Tool to implement the Service Model.

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0012/205500/cdmp-self-assessment-process.pdf

Format: PDF File (353.7 KB) Alternate Content: Plain Text

Subcategory: Chronic Disease Management Program Resource Type: Factsheets

Added: 7 January 2014 Updated: 7 January 2014

Chronic Disease Management Program Service Model and Self-Assessment Process

The Service Model describes the CDMP’s core principles, elements and resources. The Self-Assessment Tool is intended to assess the delivery of the program against the Service Model.

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

Format: Webpage

Subcategory: Chronic Disease Management Program Resource Type: Clinician Summaries

Added: 14 November 2014 Updated: 30 November 2017

NSW Chronic Disease Management Program - Connecting Care in the Community

The CDMP provides care coordination and self-management support to help people with chronic disease better manage their condition and access appropriate services in order to improve health outcomes, prevent complications and reduce the need for hospitalisation.

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

Format: Webpage

Subcategory: Chronic Disease Management Program Resource Type: Clinician Summaries

Added: 7 January 2014 Updated: 19 May 2017

Chronic Disease Management Self-Assessment Tool

The Chronic Disease Management Program Self-Assessment Tool will build a better understanding of how the service connects, and delivers quality person centred care across the range of chronic disease programs and services available to people with chronic disease.

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0013/205501/self-assessment-cdmp.pdf

Format: PDF File (409.3 KB) Alternate Content: --

Subcategory: Chronic Disease Management Program Resource Type: Checklists

Added: 7 January 2014 Updated: 20 August 2015

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

Added: 15 December 2014 Updated: 29 October 2015

Implementing Integrated Care Statewide Enablers

Presentations from the forum which an overview of statewide implementation regarding Patient Reported Measures, Risk Stratification and Chronic Disease Management redesign

https://aci.health.nsw.gov.au/resources/chronic-care/aci/implementing-enablers-dec2015

Format: Webpage

Subcategory: ACI Integrated Care Resource Type: Presentations

Added: 11 January 2016 Updated: 30 May 2016

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

Added: 26 August 2015 Updated: 29 October 2015

Patient and Consumer Engagement in Chronic Care

https://aci.health.nsw.gov.au/resources/chronic-care/chronic-care-event-videos/patient-and-consumer-engagement-in-chronic-care

Format: Webpage

Subcategory: Chronic Care event videos Resource Type: Clinician Summaries

Added: 1 February 2016 Updated: 1 February 2016

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

Added: 16 September 2016 Updated: 16 September 2016

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

Added: 16 September 2016 Updated: 16 September 2016

Participant experience focus groups

This page includes the guide and tempaltes to show 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/resources/chronic-care/participant-experience-focus-groups/participant-experience-focus-groups

Format: Webpage

Subcategory: Participant experience focus groups Resource Type: Clinician Summaries

Added: 19 October 2016 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

Added: 28 September 2016 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

Added: 10 January 2017 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

Added: 6 February 2017 Updated: 10 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

Added: 10 February 2017 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

Added: 10 February 2017 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

Added: 19 September 2016 Updated: 19 November 2018

Analysis of tools that measure enablement

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0010/460468/Analysis-of-tools-that-measure-enablement.pdf

Format: PDF File (1.1 MB) Alternate Content: --

Subcategory: Consumer Enablement Resource Type: Other

Added: 18 January 2019 Updated: 18 January 2019

Consumer Enablement Guide

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

Format: Webpage

Subcategory: Consumer Enablement Resource Type:

Added: 27 September 2018 Updated: 30 November 2018

Consumer enablement: evidence check

This evidence check is part of the development process of a framework for consumers to participate in the management of their healthcare and ongoing treatment decisions.

https://aci.health.nsw.gov.au/__data/assets/pdf_file/0006/351429/Consumer_enablement_evidence_check.pdf

Format: PDF File (2.4 MB) Alternate Content: --

Subcategory: Consumer Enablement Resource Type: Reports

Added: 14 March 2017 Updated: 14 March 2017

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

Added: 29 September 2017 Updated: 13 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

Added: 29 September 2017 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

Added: 5 December 2017 Updated: 5 December 2017

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

Added: 29 September 2017 Updated: 13 October 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

Added: 29 September 2017 Updated: 13 October 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

Added: 29 August 2018 Updated: 28 February 2019

Chronic Care Network

Contact

Jenny Caspersonn
Manager, Chronic Care Network

+61 2 9464 4682

jenny.caspersonn@health.nsw.gov.au