Chronic Care

Lower Hume PCP work with member agencies to improve chronic care through:

  •  Strengthening system integration and communication within and between services to provide early intervention and integrated care, and;
  • Supporting the implementation of person-centred models of care and initiatives that build health literacy to empower consumers to be active participants in their health.

Ovens Murray Chronic Care Strategy

The Ovens Murray-Goulburn Chronic Care Strategy is intended to guide the actions of a wide range of public and private organisations and health professionals as well as organisations beyond the health sector who play critical roles in prevention of chronic conditions, and then support, care and management of people living with chronic conditions in the Ovens Murray & Goulburn Areas. The Strategy sets out priority areas and desired outcomes for the short and medium term, together with longer term aspirational outcomes. Successful implementation of actions will rest on how organisations and their workforce respond to developments in chronic conditions health service delivery in their local context and will be supported by PCPs.

Expanded Chronic Care Model

The Expanded Chronic Care Model (Figure 1) is an evidence based framework used to support agencies to implement continuous improvement strategies. The Expanded Chronic Care Model recognises that change will be less costly and more effective if both the prevention and ongoing management of chronic illnesses use a similar set of improvement strategies. As such the Expanded Chronic Care Model aims to reduce the burden of chronic disease by reducing the impact of those who have the disease (tertiary prevention), identifying risk factors to prevent disease onset (secondary prevention) as well as supporting communities to be healthy (primary prevention). This is achieved through action on the social determinants of health as well as access to high quality health services.

The following frameworks and resources support the implementation of chronic care improvements:

  • National Strategic Framework for Chronic Conditions
  • Care for People with Chronic Conditions: Guide for Community Health Program

Additional Resources/Information




1. Diabetes services and supplies in Lower Hume

2. Understanding Diabetes

3. Diabetes Management

4. Living with Diabetes

5. Other resource forms & links

Links: for some useful links, please see our links page