Chronic Care Program

The Chronic Care Program (CCP) targets frequent users of the acute sector with HF, COPD, PD and other conditions by arrangement. Clinical care coordinators provide individually tailored services including self-management strategies, Advance Care Planning, education, facilitation and coordination of community and other support services.
Clinical Services:

  • Care Coordination Service
  • Advance Care Planning Service
  • Chronic Disease Management Home Telemonitoring Service

Care Coordination Service

Care coordination is provided by a clinical care coordinator who may be qualified as either a nurse or an allied health professional. 
A comprehensive patient-centred assessment is performed. Goal setting interventions are then developed with the patient and the health professionals involved in care. The aim is to assist in maintaining a coordinated approach to managing the patient’s condition. The care is client-centred, focussing on the development and/or support of self-management skills. Our aim is to assist the client to remain well in the community, navigate and engage with our health system and prevent unnecessary hospital presentations and admissions. 

Eligibility criteria 

  • Adult (> 18 years old) ACT resident 
  • Under the care of a relevant specialist (cardiologist, neurologist/geriatrician or respiratory specialist) with a documented medical management plan for their Heart Failure, Chronic Obstructive Pulmonary Disease, Parkinson’s Disease or other conditions by arrangement with the Chronic Care Program Manager 
  • Has a need for psychosocial or clinical assistance to overcome barriers that may be affecting the patient from self-managing their chronic condition 
  • More than 2 presentations per annum to hospital related to their chronic condition 

For clients who are acutely psychiatrically unwell, referral to a mental health service is the most appropriate response. 

Please see our referral form here and consumer handout here.
For more information, please contact us on 02 6244 2273 or email: chroniccareprogram@act.gov.au

Advance Care Planning Service

The Chronic Care Program (CCP) staff are available to assist patients in the Chronic Care Program complete Advance Care Plans. This can be done in the patient’s home or in a community health/ outpatient setting.

Advance care planning (ACP) provides people over 18 with an opportunity to plan and record their health care preferences in case they become ill or injured and unable to express these wishes.  These preferences may include but are not limited to, end-of-life decisions.

Advance care planning is based on people having the right to be informed about their medical options and to be treated in ways which respect their dignity and prevent suffering.
The process involves health professionals discussing with people and their families the likely progression of, and treatment options for, illnesses or injuries.  This information can then be considered and informed choices made about future health care.

Advance care planning can involve nominating a substitute decision-maker who will be able to talk to medical staff about a person's health care preferences if they are unable to do so at the time.  Usually, this person is a family member or a close friend, someone who can be trusted to act in the person's best interests and respect their previously expressed wishes.
Advance care planning also gives people the opportunity to record their preferences about specific treatments or document their views regarding unacceptable outcomes.

Then, if they are unable to speak for themselves when the time comes, Advance Care Plan – the documents previously completed – provide health professionals and substitute decision-makers with the person's wishes about treatment and acceptable outcomes.
For more information, please visit the Advance Care Planning Australia website.

Home Telemonitoring Service

The home telemonitoring service is based on the principles of patient centered care and self-management. The aim of the home telemonitoring service is to provide a mechanism which supports clinical staff to enable patients to self-manage their chronic disease more effectively, increasing their confidence and ultimately contributing towards improving their quality of life. 

Monitors are set up in the patient’s home for the patient to measure their vital signs. The patient can see the vital sign results on the monitor, and the results are sent electronically to the portal.  A registered nurse monitors the results from the portal. 

The home telemonitoring service offers the ability to:

  • identify an early deterioration in health status potentially leading to reduced frequency Emergency Department presentations and admissions to hospital
  • monitor the effect of and response to specific therapy
  • monitor progress after treatment of acute disease exacerbation
  • improve patient knowledge and capacity to self-manage

For more information, please contact us on 02 6244 2273 or email: chroniccareprogram@act.gov.au

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Page last updated on: 12 Oct 2018