Prevention and Management of Long Term Conditions

Description and Aims

This stream is a response to the challenge of long term conditions to health and health care services.   These conditions include diabetes, cardiovascular disease, asthma and chronic obstructive lung disease, cancer and mental illness.  They commonly occur as multi-morbidities.   The aim is conduct research in the community which informs improvement in health care and programs which aim to prevent and manage these conditions. 

Key Current Research Areas
·         Prevention

The program focuses on improving interventions to address the behavioural risk factors (especially Smoking, Nutrition, Alcohol and Physical activity) as well as physiological risk factors such as obesity and cardiovascular risk in primary health care.  This uses the 5As framework (ask/assess, advise, agree and assist, arrange), approaches tailored to health literacy levels and use of wearable technology and social media. 

·         Management

This program focuses on a patient centred approach based on the Chronic Care model and includes teamwork, information and communication systems (including e-health), self-management support and community resources.  This is the focus of work on diabetes, cardiovascular disease, asthma, COPD, cancer, mental illness and multi-morbidity. 

Key Partners

This research is conducted in partnership with primary health networks and local health districts along with other groups including  Aboriginal Health organisations.

Stream lead

Mark Harris leads the stream.  


Innovative Models Promoting Access & Coverage Team (IMPACT)

Innovative Models Promoting Access & Coverage Team (IMPACT)

The IMPACT study is a five-year international research program that aims to develop and evaluate models of care that enhance access to primary health care for vulnerable populations in six sites across Australia and Canada. 

Preventing chronic disease in patients with low health literacy using e-health in general practice.

Preventing chronic disease in patients with low health literacy using e-health in general practice.

This is a cluster randomised controlled trial of the effectiveness of an intervention which uses accessible and interactive information technology to support general practice nurses to better communicate with patients with low health literacy, to help them use information, set priorities, navigate referral and maintain behaviour change.

Review of Chronic Disease Management interventions provided by NSW Health (commissioned by NSW Ministry of Health)

This review project commissioned by the NSW Ministry of Health aims to inform the development of a shared understanding of care navigation, care coordination and health coaching based on the literature and the experience of existing programs in NSW.

TCRN Cancer Project

Cancer patients, their cancer specialists and GPs were interviewed about expanding the role of GPs in the long term care of patients with cancer.  This identified the need for a shared care plan between the hospital specialist services and GPs.  




An evaluation of the development, implementation, feasibility and impact of a tailored intervention to improve the quality of care for Aboriginal and Torres Strait Islander peoples attending urban general practice

This study aims to develop and evaluate strategies to improve the acceptability of health care provided to Aboriginal and Torres Strait Islander patients who attend mainstream general practice in urban Sydney.

Analysis of patterns of diabetes care and their outcomes from division registers

Division registers provide longitudinal data on the quality of care and health outcomes for patients with diabetes in general practice. The Macarthur and Southern Highlands Divisions have 9 been established for more than 9 years.

Barriers and facilitators of influenza vaccination in high risk groups aged less than 65

This study was done to explore issues in relation to influenza vaccination among people aged less than 65 years of age with high-risk factors.

Barriers and facilitators to use of the asthma 3+ visit plan

The Asthma 3+ Visit Plan is an initiative of the National Asthma Council to promote organized care of asthma in general practice. This study explores barriers and facilitators to Asthma 3+ Visit Plan in general practice.

Community Health Risk Factor Management Research Project

This study aims to increase the capacity of community health services to address chronic disease risk factors of smoking, nutrition, alcohol and physical activity as part of their normal clinical work.




No projects found.