Chronic Disease Management and Prevention Services

The Western NSW Primary Health Network has commissioned the NSW Outback Division of General Practice (NSWODGP) led consortium involving NSWODGP, Maari Ma Health Aboriginal Corporation and Bila Muuji Aboriginal Health Services to develop and implement a Chronic Disease Management and Prevention Program CDMPP), commencing 1st September, 2017.

The Chronic Disease Management and Prevention Program covers the entire region of the Western NSW Primary Health Network (WNSWPHN), the largest geographical region of all Primary Health Networks in NSW. 

The program oversees four regions representing the South West, Far West, North West and Central West of Western NSW.  The regions in turn are represented by five Distinct sub-regions, referred to as ‘Lots’.  Within each sub-region, 8 Local areas have been identified that encompass a cluster of townships, referred to as Health Care Neighbourhoods.


Regional General Practice Local Areas




Cowra, Parkes, Forbes, Grenfell, Canowindra



Dubbo, Wellington, Dunedoo, Baradine, Coonabarabran, Gulargambone, Gilgandra, Trangie, Narromine, Peak Hill



Mudgee, Gulgong, Rylstone, Kandos



Bathurst, Oberon, Blayney



Orange, Molong, Manildra



Bourke, Brewarrina, Walgett, Lightning Ridge, Cobar, Condobolin, Nyngan, Coonamble, Warren, Tottenham, Tullamore,



Broken Hill, Wilcannia, Menindee, Ivanhoe



Wentworth, Balranald, Dareton, (Mildura)



  1. The South West Region covers Lot 1, and the neighbourhoods of Wentworth, Balranald, and Dareton
  2. The Far West Region covers Lot 2, and the neighbourhoods of Broken Hill, Wilcannia, Menindee and Ivanhoe
  3. The North-West Region covers Lot 3 and the Neighbourhoods of Bourke, Brewarrina, Walgett, Lightning Ridge, Cobar, Condobolin, Nyngan, Coonamble, Warren, Tottenham and Tullamore
  4. The Central West Region covers Lots 4 and 5, and the Neighbourhoods of Orange, Molong, Manildra, Bathurst, Oberon, Blayney, Mudgee, Gulgong, Rylstone, Kandos, Dubbo, Wellington, Dunedoo, Baradine, Coonabarabran, Gulargambone, Gilgandra, Trangie, Narromine, Peak Hill, Cowra, Parkes, Forbes, Grenfell and Canowindra.

The CDMPP is directed toward patients and communities at highest risk, including Aboriginal and Torres Strait Islander, disadvantaged (SEIFA rating), and people living in isolated, remote communities where there is a higher prevalence of Chronic Disease and lower access to health care services. 

The CDMPP framework is designed to be responsive to the diverse regional health care capabilities, targeting areas experiencing high workforce market failure through increased program funded services while maximising the effectiveness of existing services in well-resourced regions.  The program ensures resources are directed toward filling service gaps where they are most needed while strengthening existing health service capability throughout the region.  

The incidence and burden of Chronic disease for communities living in Western NSW is considerably higher than the NSW and Australian average.   For the broader population, premature mortality is significantly greater for the WNSWPHN region than averages for NSW and Australia.  The high incidence of chronic disease and premature mortality is attributed to the following contributing factors:

·      Socioeconomic Disadvantage

·      Geographical Isolation

·      Low Levels of access to health services

·      Poor health among Aboriginal People who comprise a significant proportion of the Western NSW population.[1]

Brewarrina, Central Darling, Walgett and Broken Hill Shires are ranked 1st, 2nd and 4th and 9th as the most socially disadvantaged LGAs in NSW. SEIFA rankings are not available for the Unincorporated Far West.  As a whole, communities within the Far West of NSW are ranked as the most disadvantaged in NSW in terms of relative socio economic disadvantage.[2]  The burden of chronic disease for communities increases with geographical remoteness where the contributing factors are more extreme.

Access to appropriate health services is a key challenge to the prevention and management of Chronic Disease in Western NSW.  Many residents living outside the main population centres have to travel long distances to access primary health care. There is limited public transport and a low rate of motor vehicle ownership while the cost of accessing health services is often unaffordable for communities, particularly in areas of high socioeconomic disadvantage.  The region reports low internet access in homes that impacts upon the uptake of telehealth support for Chronic Disease Management.[3]

Service providers have difficulty attracting, recruiting and retaining skilled and experienced health professionals, particularly in the more remote Western regions where the allied health workforce is inadequate and General practices are highly reliant on overseas trained doctors with conditional area of need registration.  The nursing workforce in particular is ageing.  Health professionals in the region can find it difficult maintaining and updating professional skills and knowledge.  While the health workforce is dedicated and committed, excessive demands often outweigh workforce capability and can lead to burnout.  There is also a poor alignment of health professionals’ skills and scope of practice with models of care.

The burden of chronic disease is a serious problem for Aboriginal and Torres Strait Islander people in the CDMPP region, where the rate of hospitalisation for chronic disease is up to 100% higher than the rate of non-indigenous populations in the Far West of NSW.   Compared with rates for non-Aboriginal people, hospitalisation for Aboriginal people in NSW are:

· 200% higher for diabetes

 · 70% higher for cardio-vascular disease

· 100% higher for chronic respiratory disease

 · 60% higher for injury and poisoning. [4] 

The relative socio-economic disadvantage experienced by Aboriginal people in NSW continues to place them at greater risk of exposure to behavioural and environmental health risk factors. Aboriginal people generally have poorer health than the than the rest of the population. The Aboriginal population experience a higher infant mortality, lower life expectancy, higher rates of chronic disease risk factors, higher prevalence and earlier onset of chronic illnesses (in particular respiratory illness, diabetes and renal disease), higher rates of hospitalisations.  Chronic disease is becoming normalised as entrenched social norms and behaviours are contributing to chronic conditions amongst the Aboriginal population.[5]

Aboriginal people are more than 3 times as likely as non-Aboriginal people to die as a result of diabetes. Aboriginal people are admitted to hospital at about 1.7 times the rate of non-Aboriginal people and renal dialysis accounts for the largest number of hospitalisations for Aboriginal people.

In comparison to the non-Indigenous population, Aboriginal and Torres Strait Islander people in the WNSWPHN region are more likely to be admitted for a preventable hospitalisation and be discharged against medical advice.

Health outcomes in the WNSWPHN region are generally poorer compared to the rest of NSW and Australia.  For the broader population, premature mortality is significantly greater for the WNSWPHN region than averages for NSW and Australia. In the Western NSW LHD over 70% of the populations? death rate is attributable to chronic diseases including: cardiovascular disease, cancer, respiratory disease and diabetes. [6]

The CDMP program provides the opportunity to deliver better chronic disease management for at risk people with the highest need in Western NSW.   It is a key program for improving wellbeing of the community of Western NSW.  It has the potential to empower General Practice and Aboriginal and Torres Strait Islander organisations and their relationships with the wider health system, and to engage people with chronic disease more effectively in their care.

[1] Western NSWLHD Chronic Disease Services – Service Plan – 2012 to 2016

[2] 2014 FWML comprehensive needs assessment

[3] 2014 FWML comprehensive needs assessment

[4] Western NSWLHD Chronic Disease Services – Service Plan – 2012 to 2016

[5] 2014 FWML comprehensive needs Assessment

[6] Western NSWLHD Chronic Disease Services – Service Plan – 2012 to 2017


The CDMPP service model is clearly focussed toward the management and treatment of patients with Chronic Disease who are 15 years and over, primarily targeting Vascular Disease as a population needs priority.  The funding and eligibility criteria for this model of care ensures funding is directed toward the highest area of need to provide the most effective cost-benefit return on investment in relation to service outcome delivery.  The funded service delivery formula is consistent across the region with flexibility to be adapted to the specific health care needs of each local community.

The service delivery framework supports an integrated model of general practice led multidisciplinary primary care, providing complementary service delivery to manage overlapping patient needs without the duplication of roles and responsibilities

Our model of General Practice led multidisciplinary care, strengthens the capability of the patient’s Health Care Home and provides the platform for the development and coordination of clinical networks within designated health care neighbourhoods to deliver primary health care services needed where people reside. 

The CDMPP model is designed to empower general practice teams to lead patient centred care, with support from specialist services and allied health providers within a regional service delivery relevant area. The Service delivery model incorporates the following key strategies:

  • General Practice enrolment linked to the resourcing of CDM Practice Nurse, Allied Health, Aboriginal Health Worker, Chronic Disease Support Team and Quality Improvement strategies to implement CDMP models of care in each identified General Practice.
  • Chronic Disease Nurse support to General Practices to provide identified Practices with additional specialist resources to lead and implement the CDMPP Model of Care
  • Aboriginal Health Worker support in Health Care Neighbourhoods to improve access to culturally responsive Chronic Disease Management for Aboriginal people.
  • Allied Health Strategy that involves the provision of Dietitians/Exercise Physiologists, Diabetes Educators and Podiatrists in Health Care Neighbourhoods where needed to increase access and support for patients referred under a GP Led Multidisciplinary Care plan.
  • A Quality Improvement (QI) Strategy that is focussed on strengthening the capability of enrolled General Practices to better manage patients with Chronic Diseases within the scope of the CDMP program to provide better health outcomes.  Include “prevention” functions and activities in all clinical positions who will perform a 85:15 clinical:health promotion role
  • Care Coordination” within the core positions of Chronic Disease Management Practice Nurses practice nurses and Aboriginal Health Workers.
  • Promote the use of digital activities such as telehealth and secure messaging through General Practice to increase patient access to care.