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NSW Chronic Disease Management Program – Connecting Care in the Community

Purpose

The NSW Chronic Disease Management Program – Connecting Care in the Community (CDMP) is a free service for people with chronic disease who have difficulty managing their condition and who are at risk of hospitalisation.

The CDMP provides care coordination and self-management support to help people with chronic disease better manage their condition and access appropriate services in order to improve health outcomes, prevent complications and reduce the need for hospitalisation.

The CDMP connects the person and their carer with appropriate primary, community and acute care services by:

  • Proactively identifying people most in need of and likely to benefit from the program
  • Undertaking comprehensive assessment
  • Supporting shared care planning
  • Delivering care coordination and self-management support services
  • Regularly monitoring and reviewing participants

People in NSW aged over 16 years who have been in hospital or need more support to manage their needs are eligible for enrolment to the program. The target chronic diseases are Diabetes, Congestive Heart Failure, Coronary Artery Disease, Chronic Obstructive Pulmonary Disease and Hypertension, recognising that people with these diseases often have multimorbidities such as depression, arthritis and dementia.

The CDMP actively seeks to enrol and support people with complex needs who are at high risk of hospitalisation including Aboriginal people and frail elderly people. Other populations may also be prioritised for enrolment including people from culturally and linguistically diverse backgrounds, people with mental illness, people of low socio-economic status, people living in rural and remote locations and people living alone.

Redesign

The Program has provided enhanced and more integrated care across NSW.  Chronic Disease Management is no longer a separate entity but is now part of the Ministry’s broader Integrated Care strategy. Overall sponsorship of Chronic Disease Management is with the System Purchasing and Performance Division of the Ministry, who also has carriage of the CDMP redesign process.

The CDMP was evaluated by an external consortium led by The George Institute for Global Health. The final report is available on the NSW Health website.

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