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

  • Administrative Officer
  • Clinical Care Coordinators
  • Registered Nurses
  • Program Nurse Manager (Clinical Nurse Consultant)
  • Medical Director

Clinical Care Coordinators provide:

  • Arrange support services for the patient in the community to assist health management
  • Provide patient education and strategies to help self-manage their condition
  • Provide ongoing patient contact via home visits and phone consultation
  • Liaise and advocate with patient’s GP, Specialist and other health care professionals/service providers regarding appointments and health management
  • Discuss and complete Advanced Care Planning in line with patient’s wishes 

How Do You Access the 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.

Information for Clinicians

To refer a patient to the Chronic Care Program please fill in the referral form below:

Chronic Care Program Referral Form

Contact Us

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