Chronic Disease Services

Chronic Disease Management Services are provided to residents of the ACT and surrounding areas by the ACT Health Directorate, through the Chronic Care Program and the Obesity Management Service. The services provide care coordination and/or clinical support to people with Chronic Obstructive Pulmonary Disease (COPD), Chronic Heart Failure (CHF), Parkinson's Disease (PD) and other movement disorders, and/or obesity.

ACT Health's Chronic Disease Management Service also provides Home Telemonitoring and Telephone Coaching.

Obesity Management Service

The Obesity Management Service was established in January 2014 and has been operational since February 2014.

Chronic Care Program

The Chronic Care Program (CCP) provides care coordination and/or clinical support to people in the ACT and surrounds with Chronic Obstructive Pulmonary Disease (COPD), Chronic Heart Failure (CHF) and Parkinson's Disease. It focuses on those people who may need assistance to manage their health and to navigate the ACT health care system. It aims to:

  • Encourage self-management at home or in community settings, including the use of peer-support and technology where appropriate;
  • Provide education and support to the patient, their carers and family, and assist with accessing appropriate health and community services; and
  • Enhance communication among the Chronic Care Program (CCP) partners involved in the patient’s care, enabling more effective and timely monitoring and management of the patient’s condition.

In 2012 the Chronic Care Program was awarded 'Team of the Year' at the International Nurses and Midwives Week awards.

Team Members

Most team members are Registered Nurses and include the following:

  • Administrative Officer
  • Clinical Nurse Consultants for each of the three CCP services (COPD, HF and PD)
  • Clinical Care Coordinators (including social workers and registered nurses)
  • Program Nurse Manager (CNC)

Clinical Nurse Consultants provide:

  • Patient centred care to individuals & their families living with Heart Failure, Chronic Obstructive Pulmonary Disease and Parkinson's and Movement Disorders
  • Clinical assessment through the Heart Failure clinic, Chronic Obstructive Pulmonary Disease Clinic and Parkinson's/Movement Disorders Clinic
  • Education for patients & their families regarding their chronic illness
  • Development & implementation of individualised patient management plans
  • Access to support & information regarding Heart Failure, Chronic Obstructive Pulmonary Disease and Parkinson's and Movement Disorders
  • Access to timely referrals & appointments

Clinical Care Coordinators provide:

  • Clinical assessment and review coordination
  • Education for patients and their support networks regarding their chronic illness
  • Development and management of individual care plans
  • Access to support and information regarding Heart Failure, Chronic Obstructive Pulmonary Disease and Parkinson's and Movement Disorders
  • Active communication between client’s community and health care providers and assistance arranging community services
  • Assistance with the completion of Enduring Power of Attorney and Advanced Care Plan through Advance Care Planning Clinics

How Do You Access the CCP Service?

You are eligible to be referred to this service if you have had one or more of the following:

  • For CHF - More than 2 non-admitted emergency presentations per annum
  • For COPD - More than 3 non-admitted emergency presentations per annum
  • For HF & COPD - More than 2 admissions in the last two years
  • For Parkinson's Disease and other movement disorders - Diagnosis of Parkinson’s Disease (PD), Multiple Systems Atrophy (MSA), Progressive Supranuclear Palsy (PSP) or Corticobasal Degeneration (CBD)

Your primary health care provider will need to refer you to this service.

Chronic Care Program Information Sheet

Information for Clinicians

To refer a patient to the Chronic Care Program please fill in the Referral Request Form below or refer via Community Health Intake.

Chronic Care Program Referral Request Form

Contact Us

For more information on any of our services, please feel free to contact us.