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

Resources

Prevention and early intervention

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

Prevention

My Health for Life – access referral form here
Quit smoking – Get help from Quitline

Chronic disease

Self Management of Chronic Conditions (SMoCC) service

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

Ways We Help | Kidney Health Australia

Stroke

Stoke Foundation For survivors and carers

Musculoskeletal

Bone Health – Find a Health Service
Musculoskeletal Australia (MSK) – get support

Complex Needs

Nurse navigators: information sheet and questions and answers

Health Professionals online directories

Visit your local Health pathways webpage for information about local support programs.

PHN funded 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.