Chronic Disease Management

The CWGPCP is committed to improving the quality of care and quality of life of people living in Gippsland through a coordinated, collaborative region wide approach to Integrated Chronic Disease Management (ICDM)

The ICDM program supports the development of an integrated community-based and person centred approach to the prevention and management of chronic disease, based on the Chronic Care Model developed by Ed Wagner and colleagues at the McColl Institute for Healthcare Innovation. The Wagner model proposes a proactive approach to chronic disease, focusing on keeping clients as healthy as possible. It advocates for healthcare systems improvements, community involvement in planning, and the development of self management support for clients.


The PCP’s support for ICDM builds on the earlier work of the Better Healthcare in Gippsland (BHCiG) Project (2004-2006). This project adopted a coordinated regional approach to improving services for people at risk of or experiencing chronic disease, piloting a chronic disease management care pathway protocol in 3 Gippsland sites.


The PCP aims to contribute to improvements in chronic disease care by:
  • Promoting and supporting the implementation of the Wagner Model of Chronic Illness Care
  • Facilitating and supporting Working Groups and other ICDM networking activities.
  • Actively promoting and providing training in the use of the Better Health Care in Gippsland (BHCiG) Chronic Disease Management Resource Kit and training package.
  • Building the capacity of health care providers to deliver improved care to people with a chronic illness, by providing training, networking and mentoring support in all aspects of the chronic care model.
  • Participating in the ongoing development of a Gippsland Regional ICDM Training Plan.
  • Supporting the development, implementation and ongoing review of funded projects.