Chronic Disease Management

The Chronic Disease Management (CDM) program works to engage with GPs, AHPs, practice nurses and practice staff to enhance chronic disease management and optimise preventative health strategies.

The program offers support, training and assistance with:

  • MBS Primary Care items e.g. health assessments, care plans, asthma and diabetes service incentive payments
  • Best practice guidelines and clinical support systems
  • The use of screening tools e.g. diabetes risk assessment tool (AUSDRISK), cardiovascular risk calculator
  • Coordinating patient care e.g. referral pathways
  • Quality Improvement activities that utilise the Pen CAT data extraction tool e.g. Putting Data into Practice initiative 
February 27, 2018


Asthma Emergency

Recognise signs of an asthma flare up or attack

How to administer first aid

Adult First Aid Asthma Chart

What is Asthma?

Asthma is a long-term lung condition. People with asthma have sensitive airways in their lungs which react to triggers, causing a 'flare-up'. In a flare-up, the muscles around the airways are squeezed tight, the airways swell and become narrow with more mucus. These things make it hard to breathe.

An asthma flare-up can come on slowly (over hours, days or even weeks) or very quickly (over minutes). A sudden or severe asthma flare-up is sometimes called an asthma attack.

One in nine people in Australia has asthma. It affects people of all ages. Some people get asthma when they are young; others when they are older.

Asthma cannot be cured, but for most people it can be well controlled by following a dialy management plan.

Asthma Symptoms - Asthma Australia

What is Asthma? - Short video by Asthma Australia


Community groups and links



February 21, 2018

Diabetes is a chronic condition where the levels of glucose (sugar) in the blood are too high. Blood glucose levels are normally controlled by the hormone insulin, which is made by the pancreas. Diabetes occurs when there is a problem with the body's production of the hormone insulin (type 1 diabetes) or how well the body can use insulin (type 2 diabetes).

1 in 20 Australian adults have reported they have diabetes while 280 Australians develop diabetes everyday.

Calculate your risk

Check your 5-year Diabetes risk using the AUSDRISK calculator or through Diabetes Australia What's my risk?

We have translated this tool into a range of languages, including:

Diabetes Management

Controlling blood sugar

It's important to keep an eye on your blood sugar (glucose). High levels of blood sugar can damage the blood vessels and cause long term health complications. Blood sugar control can be achieved by maintaining a healthy lifestyle, including eating healthily, keeping active and taking any medication recommended by your doctor.

Need help with medication? - Call Medcines Line on 1300 MEDICINE (1300 633 424) to get information about your prescription, over the country and complementary medicines from a pharmacist.

Newly diagnosed? Register with the NDSS.

Diabetes Prevention

There are different types of diabetes; the three most common types of diabetes are type 1, type 2 and gestational diabetes. Strong international evidence shows diabetes prevention programs can help prevent type 2 diabetes in up to 58 per cent of cases. You can do a lot to reduce your risk of type 2 diabetes, read our tips below.

Type 1

Currently type 1 diabetes cannot be prevented. Researchers are however looking into the autoimmune process and environmental factors that lead to people developing type 1 diabetes with the intention of reducing the instances of type 1 diabetes in the future.

Type 2

Evidence, including large-scale randomised control trials, shows type 2 diabetes can be prevented or delayed in up to 58 per cent of cases by maintaining a healthy weight, being physically active and following a healthy eating plan.

People at risk of type 2 diabetes can delay and even prevent the condition by:

  • Maintaining a healthy weight
  • Regular physical activity
  • Making healthy food choices
  • Managing blood pressure
  • Managing cholesterol levels
  • Not smoking.

Many people don't know they are at risk of developing type 2 diabetes. Assess your risk using the Diabetes Australia risk calculator. State organisations provide a range of programs and services for people at high risk of diabetes.

Pre-diabetes - Diabetes Australia

Patient Resources

Indigenous information sheets - Diabetes NSW & ACT

Bilingual resources - Diabetes NSW & ACT

Multicultural Diabetes Portal - NDSS

Gestational Diabetes - Diabetes Australia

Food and Activity - Diabetes Australia

Myths and Facts - Diabetes Australia

NDSS - Diabetes NSW & ACT

ComDiab - for people who have, or are at risk of type 2 diabetes


ComDiab is a FREE community group education program for people who have, or are at risk of type 2 diabetes. Participants will learn about type 2 diabetes and what they can do to improve their health and live well.

ComDiab is expertly designed and delivered by trained registered nurses who are accredited with Diabetes NSW and ACT. The program involves interactive group sessions to help participants to:

  • Understand diabetes
  • Make healthy lifestyle changes
  • Living with diabetes
  • Prevent diabetes complication

ComDiab is provided to complement and support the treatment and care provided by general practitioners, nurses, diabetes educators, and allied health professionals.

Programs are offered regularly across CESPHN. Below are the upcoming program schedules for Inner West Sydney:

Location: Marrickville
Date: 3 June 2019
Time: 9.30am -12.30pm
Venue: Herb Greedy Hall

Location: Strathfield
Date: 24 June 2019
Time: 1pm - 4pm
Venue: Strathfield Library

Click the links above to see the program flyers. For bookings and enquiries, call 1300 342 238 (for Inner West Sydney region).

Community Diabetes Education Programs in the South Eastern Sydney region


Programs are held at:

the Sutherland Hospital and Community Health Service (HealthOne, 126 Kareena Rd, Miranda NSW 2228).

Dates and Times:

  • 21 May 2019, 10am – 1pm
  • 25 June 2019, 6pm – 8.30pm


Research & Education Centre, St George Hospital (4-10 South Street Kogarah, NSW 2217).

Dates and Times:

  • 18 June 2019, 10.30am – 1.30pm (Seminar room 4)
  • 9 July 2019, 10am – 1pm (Seminar room 3)


Programs can be provided in other languages at request. Click here for the program flyer. 


For bookings and enquiries, call 1300 427 603 (for South Eastern Sydney region).


Other Community Groups and Programs

Beat It - Diabetes NSW & ACT

Beat It Gym is a program that runs over eight weeks and involves moderate intensity aerobic, strength and balance based exercises as well as education on healthy living topics. The sessions are fun, safe and supportive, with exercises specifically tailored to suit your individual health and fitness levels.

Please contact the Infoline on 1300 136 588 to find the Beat It program nearest to you.

Live your Life Workplace Health Program

Diabetes NSW & ACT's Live Your Life Workplace Health program - can be tailored according to individual organisation needs. Call the Infoline on 1300 136 588 for further details.

Diabetes NSW & ACT Events

Type 1 Diabetes Network

February 20, 2018

Lung disease affects more than 2.6 million Australians and puts a large financial burden on our health system:

  • Around 14% of all deaths each year in Australia are a result of lung disease
  • Around 8,000 Australians die from lung cancer each year
  • Each year, lung disease causes nearly 350,000 hospitalisations in Australia:

Lung Cancer is the fourth most commonly diagnosed cancer in both men and women:

  • Around 10,000 Australians are diagnosed with Lung Cancer each year.
  • Lung cancer is the biggest cause of death from cancer, responsible for one in every 5 deaths (19%)
  • Survival has increased over the last 26 years, but remains very low at only 13 out of 100 people with cancer surving five years beyond their diagnosis.

pdf Lung Disease in Australia - Woolcock Institute of Medical Research Report 2014 (1.40 MB)

Chronic Obstructive Pulmonary Disease (COPD) is a progressive and irreversible lung condition that affects a person's ability to breathe and can have a significant impact on their quality of life.


A recently conducted patient satisfaction survey at the Respiratory Investigation Unit RPA has revealed that many patients do not know in advance what their tests will involve and how to prepare for them. In order to address these concerns please see a brochure for referring practioners to give their patients before their appointment. You can download a patient brochure below: Respiratory Investigation Brochure.


June 13, 2014

Chronic kidney disease (CKD) presents a significant health problem in Australia with one in ten Australian adults diagnosed with CKD and one in three having an increased risk of developing CKD


CKD is defined as a glomerular filtration rate (GFR <60ml/min/1.73m2 that is present for >3 months, with or without evidence of kidney damage OR kidney damage with or without decreased GFR that is present for >3 months, as evidenced by the following, irrespective of the underlying cause:

  • albuminuria
  • haematuria after exclusion of urological causes
  • structural abnormalities (e.g. on kidney imaging tests)
  • pathological abnormalities (e.g. renal biopsy).
Risk Factors for CKD
  • High blood pressure
  • Diabetes
  • Established cardiovascular disease
  • Obesity (BMI>30)
  • Smoking
  • Aged 60 years or older
  • Aboriginal or Torres Strait Islander origin
  • Family history of kidney disease
Self Management Support
Patient Resources
Clinical Information