Service Coordination and Integrated Chronic Disease Management

Service coordination aims to place consumers at the centre of service delivery ensuring that they have access to the services they need, opportunities for early intervention and health promotion and improved health outcomes.

The practice of service coordination particularly supports more effective ways of working with people with complex and multiple needs, and are being assisted through the following areas:

Assessment of Chronic Illness Care (ACIC)

As the Primary Care Partnership provider for the Barwon South West Region, the G21 Health & Wellbeing Pillar is responsible for meeting requirements within the Integrated Chronic Disease Management component of the Primary Care Partnership Program Logic 2013 – 2017

The Assessment of Chronic Illness Care (ACIC) is used as a continuous improvement approach to broadly assess organisation-wide systems for chronic illness care.

This project aims to provide health services, within the G21 Region, the opportunity to undertake the ACIC and facilitate discussions to further improve ICDM practice.  Desired outcomes include:

  • Support of quality improvement processes based on findings
  • Provide opportunity for partnership projects and collaboration
  • To identify gaps and workable solutions in the delivery of ICDM
  • Development of a Regional Action (Improvement Plan) for the G21 region

ACIC Update (July 2016)

Implementation of the DHHS ACIC Audit tool with all Health Services. This piece of work is progressing slowly. 
A draft Regional action plan has been developed for input by key agencies.

Service Coordination Survey

A key element of Primary Care Partnerships’ work with agencies is in strengthening service coordination. The biennial service coordination survey, conducted with partner organisations is used to track progress and identify gaps relevant to the region health services and local governments.


Survey Update (July 2016)

Results were provided to services that completed the survey in March.
Feedback meetings are currently being held with individual service providers and next steps are being determined.

For further information please contact:

Project News

The Framework provides guidance for the development and implementation of policies, strategies, actions and services to reduce the impact of chronic conditions in Australia.

Related Resources

The National Strategic Framework for Chronic Conditions (the Framework) is the overarching policy document for chronic conditions that sets the directions and outcomes to achieve its Vision that “all Australians live healthier lives through effective prevention and management of chronic...