Chronic disease management
Find best practice guidelines, resources and information about chronic disease management for health professionals.
The RACGP has a collection of clinical guidelines that provide GPs with up-to-date, evidence-based resources for chronic diseases commonly seen in general practice, including:
- The Australian Asthma Handbook
- Chronic Kidney Disease Management in Primary Care
- COPD-X concise guide
- Guidelines for the management of absolute cardiovascular disease risk
- Management of type 2 diabetes: A handbook for general practice
- Heart failure guidelines
- Atrial fibrillation guidelines
- Guidelines for preventive activities in general practice
- Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age
- National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people
- Smoking, nutrition, alcohol, physical activity (SNAP)
Visit: RACGP – Chronic disease
Prevention and early intervention
- The Anaphylaxis Wallchart
- Preventive activities over the lifecycle chart– Adults
- Aboriginal and Torres Strait Islander National Guide lifecycle chart | Child
- Aboriginal and Torres Strait Islander National Guide lifecycle chart | Young people
- Aboriginal and Torres Strait Islander National Guide lifecycle chart | Adult
- The “Red Flag” Early Intervention Referral Guide for children 0 – 5 year
- Quick reference guide for health professionals Absolute cardiovascular disease risk management
- CVD Check : Calculator
- Heart Health Check Toolkit
- The Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK)
- Cardiovascular disease risk communication with Aboriginal and Torres Strait Islander Peoples – toolkit
- Supporting smoking cessation treatment algorithm
- Australian guidelines to reduce health risks from drinking alcohol
- Australian physical activity and sedentary behaviour guidelines
- Eat For Health – Australian Dietary Guidelines and resources
Cardiovascular
- Management of patients with heart failure with reduced ejection fraction
- Diagnostic work up of a patient with suspected heart failure
- Heart Failure Toolkit
- Heart Online: Heart Education Assessment Rehabilitation Toolkit
Respiratory
- Asthma Control Test
- Ascent toolkit
The Ascent toolkit has been developed for healthcare professionals working in primary care to help minimise flare-ups and maximise the quality of life in patients with asthma. The toolkit contains information and practical resources to help you and your practice identify and manage patients with uncontrolled asthma using national guidelines and recommendations. With a constantly changing treatment landscape, the resources provided have been adapted for telehealth within your practice. - How to use inhaler – videos
- Inhaler technique – Device specific checklists
- First Aid for Asthma Chart – kid
- First Aid Asthma Chart – adult
- Primary Care Respiratory Toolkit
- Managing exacerbations algorithm
- Spirometry Quick Reference Guide
- Spirometer Buyers’ Guide
- Spirometry Infection Control Recommendations for Primary Care
Diabetes
- Type 2 diabetes: Goals for optimum management list
- Diabetes Foot Risk Stratification and Triage pathways
- Type 2 Diabetes Treatment Algorithm
- Diabetes Referral Pathways guide
Osteoporosis
Pain management
Mental health
- Clinical Algorithm for monitoring metabolic syndrome in mental health patients
- Positive Cardio-Metabolic Algorithm: an early intervention framework for patients on psychotropic medication
- Mental Health and Chronic disease factsheet
Prevention
- My Health for Life – access referral form here
- Quit smoking – Get help from Quitline
Chronic disease
Cardiovascular
- Cardiac rehabilitation services
- Heart Foundation Walking groups and plans
Respiratory
- Refer to Asthma Australia – Free asthma support
- Pulmonary Rehabilitation Exercise Classes
- Lungs in Action Maintenance programs – Lung Foundation Australia
Diabetes
- National Diabetes Scheme Services: find support programs – includes Beat it, Type 2 diabetes and me, OzDAFNE
- Diabetes Queensland programs– includes DESMOND
Kidney
Stroke
- Stoke Foundation For survivors and carers
Musculoskeletal
Complex Needs
- Nurse navigators: information sheet and questions and answers
Health Professionals online directories
- National Health Services Directory
- Find a Psychologist
- Find an Occupational Therapist
- Find a Psychiatrist
- Find a Social Worker
- Find a Counsellors or Psychotherapists
- Find a Credentialed Diabetes Educator
Visit your local Health pathways webpage for information about local support programs.
Rural Primary Health Services (RPHS)
The Rural Primary Health Service (RPHS) provides allied health services for people who are currently at risk of a chronic condition or managing an existing chronic condition(s). The program runs in the North Burnett, Discovery Coast and Central Queensland where health services are limited and health needs are high (i.e. a high rate of risk behaviours, high rates of chronic conditions).
The services that are funded are those able to bill to Medicare under a GP Management Plan such as Aboriginal and Torres Strait Islander health practitioner, audiology, chiropractic, dietetics, exercise physiology, occupational therapy, osteopathy, physiotherapy, podiatry, psychology, and speech pathology.
There are three service providers implementing the RPHS program, please find below the provider for Central Queensland, Discovery Coast and North Burnett along with their contact details should you wish to enquire about the service.
- Central Queensland
LiveBetter
1800 580 580
- Discovery Coast
IMPACT
07 4902 2000
- North Burnett
RHealth
07 4638 1377
Prevention
- Exercise is Medicine Australia
- RACGP – SNAP your patients into healthier lifestyle
- Motivational interviewing
- RACGP – Delivering brief interventions for children above a healthy weight
- Brief Interventions for a Healthy Lifestyle
Chronic Disease management
- Practice Coaching – includes free e-learning on Chronic Disease Management and Health promotion. This website is an initiative of South Eastern Melbourne PHN
- Chronic Disease Management and Care Planning Education for Coordenated Veteran Care Program Nurses
- Chronic disease and mental health e-learning program
Diabetes
- National Diabetes Scheme Service
- Diabetes Queensland
- Foot forward for Diabetes
- Diabetes at the Royal Children’s Hospital: Diabetes webinars
- Diabetes Australia
Respiratory
- Lung Foundation Australia
- Severe Asthma
- Spirometry training: Asthma Australia
Cardiovascular
Mental health

Need support?
Our Primary Health Care Support team is available to provide one-on-one support. Please email pracsupport@ourphn.org.au.