Chronic conditions are the leading cause of illness, disability and death in Australia.  The most recent study on the impact and cause of illness and death in Australia (AIHW 2016) indicates that chronic conditions now cause most of the burden of ill health.

The personal, social, and economic impacts of disease become increasingly complex and burdensome with each additional condition. And while chronic disease is found across all parts of our society, the most vulnerable tend to be impacted most frequently and profoundly.

The north western Melbourne region has extremely high rates of diabetes compared to the Victorian and national average, particularly in Brimbank, Hume, Maribyrnong, Darebin and Moreland. Mortality rates from cardiovascular disease are very high in some areas, and, significantly, chronic disease accounts for a significant proportion of potentially preventable hospitalisations.

To limit the impact of chronic conditions across the north western Melbourne region, we commission activities that:

  • increase the efficiency and effectiveness of medical services, particularly for patients at risk of poor outcomes; and at the same time
  • improve coordination of care to ensure patients receive the right care in the right place at the right time.

In 2016-2017 our PHN commissioned over $1.5 million to support the prevention and management of chronic conditions in the north western Melbourne region.

We use a range of strategies, mechanisms and tools to support our work in this area:


Population based approaches

Our work in the prevention and management of chronic conditions is underpinned by our knowledge of the north western Melbourne region.  By understanding and identifying need, we can prioritise and plan our activity to target populations who need it most.  Read here about how we support priority populations in Hume, Brimbank and Moreland to better self-manage their chronic conditions.


Supporting primary care

To encourage consistent and best-practice care for chronic conditions in primary care, we offer chronic disease specific:

  • training and education;
  • information and resources;
  • business tools.

Read how our PHN supports primary care providers to manage hepatitis B and hepatitis C.


Workforce development

Our PHN supports primary care nurses to take a greater role in the management of chronic conditions. Read how General Practice and Primary Care Nurses  are supporting patients to better understand and manage their chronic conditions through the CareFirst program.


HealthPathways Melbourne

HealthPathways Melbourne is a web-based system that helps coordinate patient care across the acute and primary care system.  A range of pathways have been developed for use by health professionals in the assessment, management and referral of chronic conditions.

Read how HealthPathways Melbourne supports our work in implementing Optimal Care Pathways for cancer.


Optimal care pathways for cancer

NWMPHN is implementing the Optimal Care Pathways (OCP’s) for cancer across our region. This is part of the Victorian Department of Health and Human Services statewide integrated approach to optimal care pathways. The aim is to improve patient outcomes by facilitating optimal care using evidence-based pathways of care.


Optimal care pathways prostate cancer education in 5 parts: (Total 105min)


Dr Anita Munoz | GP and Clinical Editor, HealthPathways
Dr Homi Zargar | Urologist
Mr Dave Gray | Nurse Practitioner

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Regional Collaborations

To improve coordination of care across the health system we work collaboratively with all levels of government, general practice, primary health care service providers, local hospital networks, non-government organisations, private sector, consumers and carers.

Read here how we are working with The Collaborative to implement Stepping Up, a new model of care to support the management of diabetes in general practice.