Providing better care for patients with chronic disease

A partnership of tertiary, primary and community health services in the western metropolitan region of Melbourne is implementing a program to assist with the management of patients with chronic disease. The Chronic Disease Management Program (CDMP) aims to reduce the inappropriate and avoidable use of emergency department and inpatient services through the promotion of self-management and improved access to services in the community. While still early in its implementation, data suggests that the CDMP is having a favourable impact on self-management, and more appropriate use of health services. The recruitment of additional chronic disease cohorts will give the partnership the opportunity to evaluate whether the model of care adopted by the Program can be effectively applied across a range of chronic disease groups. Governance structures have provided a framework to assist providers to work more effectively in partnership across all sectors of the service system to meet the needs of patients with chronic disease.