Integrated Care for People with Chronic Conditions Program (formally known as “Connecting Care”)

The Integrated Care for People with Chronic Conditions Program (formerly known as Connecting Care) has been developed by the NSW Health system to meet the need for integrated care across primary, community and acute health settings for people with chronic conditions in NSW.

The program aims to improve the health, wellbeing and independence of people with complex chronic conditions by delivering more effective health management for patients enrolled in the program. Patients who are eligible include those who are over 16 years and are at risk of unplanned admissions to an acute care facility with one or more of the following chronic diseases:

  • Diabetes
  • Chronic Obstructive Pulmonary Disease
  • Chronic Heart Failure
  • Coronary Artery Disease
  • Hypertension
  • Renal Disease

Western NSW Local Health District in partnership with Western NSW Primary Health Network have established a model of care that focuses on the patient’s individual needs and links the health service to more effectively have the patient at the centre of care. Key features of the agreed model include:

  • General Practitioner led multidisciplinary team care
  • Comprehensive health assessment and development of a shared care plan
  • Implementation of secure messaging (ARGUS Connect) to facilitate sharing of patient information and the GP initiated shared care plan
  • Management, monitoring and integration of health and social services
  • Self-management support and health coaching

Visit our resource page for further information and website links.

Contact Us

Kathleen Ryan - Manager, Service Integration.

Phone: 02 6813 0920  Email: kathleen.ryan@wnswphn.org.au