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Facing up to Chronic Disease - Diabetes

Project Status: 

Following extensive stakeholder and community engagement, the Metro South Health (MSH) Board and Brisbane South PHN Board have endorsed the implementation of the Facing up to Chronic Disease program (proof of concept).

The strategy is a long-term plan to improve the health and wellness of the MSH population who are living with chronic disease, and reduce the social, human and economic impact of this. Diabetes is the initial focus area for the program as it is the world’s fastest growing chronic condition and a significant health problem in our community. Nearly 80,000 people in the Metro South region have been diagnosed with diabetes, and there are a further 93,000 who are pre-diabetic.

Facing up to Chronic Disease will deliver connected healthcare - establishing partnerships between the hospital and health service, community health services, general practice and allied health services to provide integrated healthcare. The program has a specific focus on ensuring general practice iswell supported to manage patients in the primary care setting where practical.

It will improve outcomes by connecting patients with community-based specialist services.

The proposed phased approach includes:

1. Formation of a Healthcare Alliance. Bringing together leaders across all levels of government and community services to drive the strategy in Metro South and to help coordinate services.
2. Development of Health Hubs. Community-based health hubs will attract GPs, specialists, nurses, allied health, education and other services to manage complex chronic disease out of the hospital setting.
3. Creation of a health and wellbeing centre of excellence. This centre will become a flagship for research, teaching and delivery of integrated services for complex chronic disease management.

The Facing up to Chronic Disease Program is being delivered in collaboration with the Brisbane South PHN Person Centre Collaborative Care program which supports interested general practices with the adoption and implementation of a patient centred medical home type model.

Aims & Goals: 

Collectively, it is anticipated the programs will:

  • reduce potentially preventable hospitalisations
  • decrease length of stay
  • decrease outpatient waiting lists
  • provide primary care the scaffolding needed to manage patients in primary care.

Most importantly, the Facing up to Chronic Disease Program aims to improve the patient journey.

Lead Service / Stream: 
Alliance for diabetes, Collaborative approach to diabetes
Last updated 18 November 2019