Chronic Disease Management Unit

The Chronic Disease Management Unit provides expertise and support in chronic disease management and service development. The unit undertakes clinical audits, continuous quality improvement, research, evaluations and management consulting. In particular, the unit is involved in the activities outlined below. We work in close collaboration with other clinical units which participate in the Chronic Disease Management Clinical Network, as well as the ANU Centre for Health Stewardship and a number of community-based organisations. 

The CDMU produces regular annual and quarterly reports, as well as ad hoc reviews and evaluations. Please contact us if you would like further information about these publications.

Chronic Disease Management Register

The unit operates the Chronic Diseases Management Register, which is a clinical information system within Canberra Hospital and Health Services. It includes case management information for various clinical services that participate in the Chronic Disease Management Clinical Network. Patients are identified for inclusion on the Register if they have been discharged from the Canberra Hospital with diabetes, chronic obstructive pulmonary disease or heart failure, or received care from services that participate in the Chronic Disease Management Clinical Network.

Chronic Disease Management Clinical Network

The Chronic Disease Management Clinical Network is a network of clinical services focussed on improving chronic disease management. The Network meets monthly and is facilitated by the Chronic Disease Management Unit.

Its aim is to improve chronic disease management through better coordination and preventive measures, discussing the care of patients who use services in the Network including newly discharged patients and patients with complex needs, and coordinating patient care between operating units.

Chronic Disease Management Consulting

The Chronic Disease Management Unit also provides a consulting service to other clinical units working in the management of long-term conditions as well as organisations that are external to ACT Health. Examples include clinical audits, evaluations, service reviews, quality projects, pilot programs and research.


Research underlies all the work we do at the Chronic Disease Management Unit. The unit workings in strong collaboration with the Centre for Health Stewardship at the Australian National University (ANU) and previously conducted research on Home Monitoring of Chronic Disease in collaboration with the CSIRO. 

Chronic Disease Management Symposium


The role of multidisciplinary teamwork in chronic disease management

The 2019 Chronic Disease Management Symposium showcased local multidisciplinary teams working on chronic diseases in services for children, mental health, pain management and rehabilitation and explored how they optimise team functioning and health outcomes. Presentations involving consumers who are living with chronic conditions highlighted that health care consumers are an invaluable member of the multidisciplinary team. The symposium concluded with an important reminder about self-care particularly when working with challenging and complex clients.

We learnt that various teams have changed or developed new models of care to provide a more effective, efficient and client centred service. Often this involved less reliance on medical professionals and greater interprofessional collaboration and care planning/interventions based on client needs and wishes. We also learnt that what is needed is not always more resources, but new ideas and ways of working that involve the various health professionals working to their scope of practice and in some areas extending it.

2019 Chronic Disease Management Symposium Program


The stigma of obesity: Exploring the barriers to quality healthcare

The 2018 Chronic Disease Management Symposium brought together policy makers, academics, administrators, non-government organisations, clinicians and consumers to participate in some thought-provoking discussions surrounding the stigma of obesity and the barriers to providing quality healthcare. The aim of this event was to provide a forum for participants to explore how stigma and discrimination may be impacting on the delivery of health services in the prevention and management of obesity. Secondly, it was hoped that participants would have a chance to reflect on their own personal beliefs and bias which will in turn allow them to increase their skills in respectful engagement.

2018 Chronic Disease Management Symposium Program

2018 Slide presentations


Practical steps toward integrated care

The 2017 Chronic Disease Management (CDM) Symposium provided a local forum for ACT Health staff, external organisations and consumers to explore new ways to effectively deliver integrated care for people with chronic conditions. Integrated care is the provision of person centred care. It involves health services working with each other and with the person with a chronic condition (and/or their carer) to ensure coordination, consistency and continuity of care over time, as well as across the different stages of the person’s condition. Given the often complex nature of the needs of people with chronic conditions, their need for integrated care is perhaps the greatest.

2017 Chronic Disease Management Symposium Program

For more information, please contact the Chronic Disease Management Unit on:

Phone: 02 5124 8376
Mail: PO Box 11, Woden ACT 2606


Page last updated on: 18 Feb 2020