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Chronic disease management and Optimal Care

Chronic disease is a major cause of hospitalisation if not addressed with adequate prevention and management strategies. People who are affected are much more likely to become frequent users of primary and acute health services. The high rates of comorbidity (that is, multiple conditions occurring together) between chronic diseases (e.g. cardiovascular disease (CVD) and diabetes), and between chronic disease and mental health difficulties, result in complex care needs and higher treatment costs.

Chronic disease management (CDM) in general practice involves appropriate prevention, early identification and best practice management strategies. Brisbane South PHN supports general practices via the following programs:

  1. Chronic disease management – Optimal Care
  2. Positive Care

For further support with information and linkages to resources to assist in optimising the management of your patients with chronic conditions, please speak with your Area Account Manager or contact the Chronic Care Team below:

Kate White
Chronic Care Manager
Megan Smith
Program Support Officer – Chronic Care
Michelle Johns
Program Support Officer – Chronic Care
T: 3864 7517
T: 3864 7551
T: 3864 7509
Kate White web

Optimal Care project

optimal care

Brisbane South PHN supports three key components essential for improved primary care management of chronic disease: Delivery system design, clinician decision support and patient self-management support.

Below is a summary of useful resources and links to assist primary care to achieve optimal chronic disease care.


Referral templates

Please click here for information on:

  • Metro South Central Referral Hub
  • Referring to local hospitals
  • Metro South Palliative Care service
  • Downloadable electronic templates for Medical Director or Best Practice software



CDM Medicare Benefits Schedule items

Medicare Benefits Schedule (MBS) items make it easier for GPs and practice nurses to manage the healthcare of patients with chronic medical conditions, including those patients who need multi-disciplinary care. For patients requiring multi-disciplinary care, GPs can also claim from Medicare for coordinating team care planning and review services. Patients with GP Management Plans and Team Care Arrangements can access a maximum of five allied health services per calendar year.

GPMP examples

Useful links and resources



Frequently used diabetes resources for general practice



Useful links

Chronic Disease Portal

The Chronic Disease Portal (CDP) tracks the prevalence of diabetes and other chronic diseases by geographic area. The brainchild of Dr Chrys Michaelides, a leading expert on diabetes treatment and management in the primary healthcare sector, the CDP tracks cardiometabolic indicators by postcode, state or by our BSPHN region. This identifies the geographic areas requiring intervention and engages these communities, GPs and clinics by providing support and resources.

The CDP provides a suite of cardiometabolic decision and management tools designed to optimise outcomes for patients, time management for GPs and business outcomes for practices. After extracting data on their practice area, general practices can then analyse their internal patient database and flag patients with relevant markers.

Click here to access the CDP portal.

Chronic respiratory diseases

The rising prevalence of chronic obstructive pulmonary disease (COPD) and asthma impacts on the cost of secondary and tertiary services, particularly in the areas of preventable emergency department presentations and avoidable hospital admissions. Brisbane South PHN has a comprehensive COPD and Asthma Health and Service Plan that was produced in response to community needs.

The key objectives of the plan are to:

  • increase consumer access to services
  • improve care coordination across the patient journey
  • reduce emergency department presentations and avoidable hospital admissions
  • reduce the severity of asthma and prevent COPD in high-risk patients.

Brisbane South PHN is committed to supporting general practice in achieving best care for patients with chronic respiratory conditions.


Asthma Annual Cycle of Care checklist

Asthma Practice Incentive Program (Asthma PIP)




Useful links

Smoking cessation

Pulmonary rehabilitation, Lungs in Action, lung support groups


Health professional resources

Chronic cardiac diseases


Chronic heart failure guidelines

Multidisciplinary care for people with chronic heart failure: Principles and recommendations for best practice, 2010 (PDF)

Acute coronary syndromes guidelines:

Acute rheumatic fever and acute rheumatic heart disease guidelines:

The Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (2nd edition)

A guide to managing hypertension:

A guide to lipid management:

Cardiac Society of Australia and New Zealand Guidelines for the diagnosis and management of Familial Hypercholesterolaemia – includes elevated lipid levels among young adults.


Chronic Heart Failure

HEART online


Useful links

Chronic kidney diseaseChronic liver diseaseObesity and lifestyle


Health assessments

Department of Health Medicare Health Assessments Resource Kit

There are additional referral options within the local community for your clients to access chronic disease self-management programs.

Healthy lifestyle and chronic disease management: Patient support options

  • Anglicare offers a generic Chronic Disease Self-Management Program across Southern Queensland. A small co-payment fee will be charged for the program. Further information can be found on their website. Please contact Anglicare via 1300 610 610 for further information.
  • Metro South Health offers a Community of Interest Group. Becoming a member is free of charge and patients will receive access to monthly workshops and newsletters around relevant health topics. For further information please visit their website or contact Tamara Swanton via 3156 4977.


Useful links

Mental healthAboriginal and Torres Strait Islander health

Related resources