Chronic conditions

Chronic conditions are not passed from person to person, they are of long duration and generally slow progression.  The four main types are cardiovascular diseases (eg. heart attack and stroke), cancers, chronic respiratory diseases (eg. chronic obstructed pulmonary disease and asthma), and diabetes.  A chronic condition usually lasts for more than three months and do not have a single, predominant condition, but rather they experience multimorbidity which is the presence of two or more chronic conditions in a person at the same time.

Chronic conditions kill nearly 40 million people every year, with cancer, diabetes, respiratory disorders, and cardiovascular disease accounting for about 80% of deaths due to chronic conditions.  Mental health is also considered a chronic condition.

Northern Queensland Primary Health Network (NQPHN) invite general practices and Aboriginal Community Controlled Health Organisations (ACCHOs) to participate in a fully funded 12-month chronic conditions management program.

The Proactive Chronic Conditions Management (ProCCM) program is a Quality Improvement (QI) program focusing on system level changes and health reform impacting general practices and their patients.

To learn more about the program, click here.

Thank you to all who submitted an application through the Proactive Chronic Conditions Management Program expression of interest (EOI). Please be advised that the EOI has now closed. Practices will shortly be advised on the outcome.

For more information, please contact the NQPHN Primary Care Engagement Team at pce@nqphn.com.au

If your patient has a chronic medical condition, they may be eligible for services under the following:

• General Practitioner Management Plan (GPMP)
• Team Care Arrangements (TCAs)
• Mental Health Case Conferences (MHCC)
• General Practitioner Management Review
• Mental Health Case Conference Review
• Medication Review

We have listed some key tools below that you can use to improve your workflow and  to help your patients improve their health and the management of their chronic conditions. These tools include:

• INCA
• GO SHARE SMS
• Primary Sense
• Education

If you have any queries or would like more information on these tools, please contact NQPHN at support@nqphn.com.au

• Guidelines for preventative activities in general practice
• MBS quick guide
• Quick guide to MBS rules and exceptions
• Nurse practitioner MBS Changes 1 July 2024
• Chronic disease GP Management Plans and Team Care Arrangements - Services Australia
• Chronic Disease Management - Practice Nurse Central
• Mental Health Case Conferencing items
• Chronic diesease videos (BING)
• Home Medicines Review | Australian Government Department of Health and Aged Care
• Item 900 - Medicare Benefits Schedule (health.gov.au)
• GoShare Healthcare (realtimehealth.com)