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Chronic Care

Chronic Care

Improving outcomes for people with chronic disease

Improving outcomes for people with chronic disease is a significant challenge that all health services face, both nationally and internationally. Current estimates suggest that 70% of the total burden of illness across Australia is attributable to chronic disease and this is expected to increase to 80% by 2020.

In our Health District, over 70% of the populations’ death rate is attributable to chronic diseases including cardiovascular disease, cancer, respiratory disease and diabetes.

More than 4.9% of our hospital separations, for the five year period 2006/07 to 2010/11 are attributed to specific chronic diseases including diabetes, heart failure, Chronic Obstructive Pulmonary Disease (COPD) and asthma. It is therefore not surprising that much of the work that has been done in our Health District focuses on these diseases.

Contact Details

David Peebles ​​​​​​​

District Chronic Care Coordinator

(02) 6369 8022 ​​​​​​​

david.peebles@health.nsw.gov.au ​​​​​

The Chronic Disease Management Program: Connecting Care in the community

The Chronic Disease Management Program (Connecting Care) is a high priority program that is being implemented in response to the Government’s Caring Together Strategy. Connecting Care is a free service intended to improve the health, wellbeing and independence of patients with complex chronic disease. We are implementing Connecting Care in partnership with Marathon Health.

Who is eligible?

Patients over 16 years of age who have at least one of the following chronic diseases and who are at risk of multiple unplanned visits to hospital for one or more of these conditions are eligible for the Program:

  • Diabetes
  • Chronic Obstructive Pulmonary Disease
  • Chronic heart failure
  • Coronary artery disease
  • Hypertension

How does Connecting Care work?

Eligible patients are offered enrolment in the Connecting Care Program via clinicians within the Western NSW Local Health District, General Practice or treating specialists. Once enrolled, the Program focuses on the patient’s individual needs and links together the health services that look after the patient.

Connecting Care provides care coordination and health coaching to help manage patient’s chronic conditions. Our Health District has three Connecting Care Coordinators, one for the Dubbo region, one for the Orange region and one for the Bathurst region.

The Connecting Care Coordinator positions facilitate the care coordination process and encourages the development of a shared care plan together with the patient’s GP and other health care providers.

If you are looking for more information about the NSW Chronic Disease Management Program, please download the brochure .

If you need to get in touch with the Connecting Care office please phone us on (02) 6369 8030.

Otherwise, you can contact a local Connecting Care Coordinator in your area.

District Manager

Patricia Haynes
Bathurst Region

(02) 6330 5657 ​​​​​​​

0418 525 356


Pieta Harrison
Dubbo Region

(02) 6809 6565 ​​​​​​​

0427 081 405


Natalia Knezevic
Orange Region

(02) 6369 3443 ​​​​​​​

0418 514 924


Carer support

Our Carer Support Program is committed to promoting carers as valued and respected partners in health care. We achieve this by educating and supporting health staff to identify and consult with carers, and to recognise carer expertise.

Chronic care for Aboriginal people: 48 Hour Follow-Up Program

The 48 Hour Follow-Up Program aims to improve the health outcomes of Aboriginal patients with chronic disease, by providing follow-up within 48 hours of discharge from an acute facility.

This follow-up may be via a phone call or a home visit and staff from each health service has been trained to provide this role.

The purpose of this program is to identify and address any concerns or outstanding issues that may lead to readmission. The Program aims to:

  • Ask patients how they are feeling and managing at home;
  • Making sure patients have access to the medications they have been given on; discharge from hospital including an understanding of what the medications are for and how to use them;
  • Asking patients whether they have a plan of care;​
  • Asking patients whether they have a follow-up appointment with their General Practitioner (GP) or healthcare provider (e.g. their local Aboriginal Medical Service).

Should any issues be identified, it is then the role of the person providing the follow-up to connect the patient to the appropriate resources, or make the appropriate referrals to someone who can assist them further. These questions are specifically tailored to the common reasons for readmission. These include not understanding ones plan of care, inadequate community follow-up and not accessing discharge medications.

It is a Ministry of Health key performance indicator that at least 90% of Aboriginal patients discharged from hospital with chronic disease receive this follow-up.

If you would like more information about the 48 Hour Follow-Up Program, please contact our Aboriginal Leadership Team by phoning (02) 6826 6132.

Primary and community health: Chronic Care Rehabilitation Service

The Chronic Care Rehabilitation Service is a multi-disciplinary service providing an evidenced-based approach to the management of individuals with chronic disease, particularly patients with Chronic Obstructive Pulmonary Disease (COPD) or chronic heart failure.

Most programs are run over 8 to 12 weeks and include a program of individually tailored exercise and education, self-management support, risk factor identification and modification and enable the patient to work towards his or her own goals in a safe and supported environment. These programs are available in most of our larger facilities.

How will this program benefit me?

These programs are designed to:

  • Identify patient’s risk factors for chronic disease and reduce modifiable risk factors;
  • Increase exercise tolerance and capacity in a safe environment;
  • Increase a person’s knowledge of their illness, supports and treatments;
  • Increase participant’s social networks (many people with advanced chronic disease can become socially isolated);
  • Increase quality of life and length of life;
  • Help patients to reach realistic health-related goals.

Program eligibility

Patients who have a diagnosis of chronic respiratory disease and/or heart failure who would benefit from the above-mentioned interventions are eligible for this program. Patients must also:

  • Have no significant musculoskeletal, neurological or cognitive impairment that would preclude the ability to participate in group-based exercise;
  • Have an absence of unstable/symptomatic cardiac disease, where exercise would be unsafe; and
  • Have a referral from a General Practitioner (GP).

Referral and more information

For referral into this program, please contact your GP. For further information, please contact our District Chronic Care Coordinator, David Peebles on (02) 6369 8022.

Quit smoking

Smoking is the most significant cause of avoidable death and disease in Australia and evidence clearly shows that smoking is responsible for numerous illnesses. Smoking increases the risk of cardiovascular disease, diabetes, Alzheimer’s disease, stroke, a range of cancers, chronic obstructive pulmonary disease, as well as increasing the risk of asthma in children exposed to smoke.

Despite the progress made in recent years to reduce smoking prevalence, smoking continues to be the nation’s largest preventable risk factors of death and illness and more than 19,000 deaths each year in Australia are tobacco-related with 5,200 in NSW alone.

Unfortunately, the risks and impacts of tobacco use do not stop with individuals who choose to smoke. Smoking creates damaging environments for people being subjected to harmful second-hand smoke. 1 in 2 long-term smokers will die from a smoking related illness.

The Western NSW Local Health District is committed to supporting smoking cessation and has setup a network of trained smoking cessation champions to provide intensive counselling and support to heavily addicted patients who wish to quit.

As this service caters for only heavily addicted patients, a General Practitioner (GP) referral to this service is required. Patients not heavily addicted can visit their local pharmacist, GP or contact the NSW Quitline.

The referral criteria for this service are:

  • Highly dependent clients who have previously tried to quit multiple times before and who have been seen by a GP or a pharmacist;
  • Clients who need to cease smoking urgently eg. prenatal or pregnant women, people requiring home oxygen therapy or surgery.

Find out more information

You can find a number of resources on quitting smoking on our Quit Sm​oking page.

Otherwise, for further information about how we can help you quit smoking, or to find a trained smoking cessation champion in your local area, please contact our Nicotine Dependence & Smoking Cessation Coordinator, Sally Bembrick by phoning (02) 6330 5823.