Chronic Disease Management & Prevention (CDMPP)

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.

The program oversees four regions representing the South West, Far West, North West and Central West of Western NSW. These regions are also classified into five sub-regions. 

Within each sub-region, eight local areas have been identified that encompass a cluster of townships, referred to as Health Care Neighbourhoods.

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 less access to health care services.