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


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.


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. 



COPD Self-management in Nepal

Globally, Primary Health Care (PHC) is recognised as central to improving health for all, yet COPD patients in Nepal are not receiving adequate PHC, due to inadequate human resources for proper diagnosis and treatment and a lack of infrastructure. Our study will be co-designing a model of care, which aims to find local solutions/innovations to the identified problems at the level of the patient, health professional and health system for improving self-management practices. We expect our program to greatly improve the quality of care and COPD patients’ quality of life in Nepal.

Development of risk profiling matrix for chronic diseases and preventive smartphone application

This project aims to promote healthy ageing through a smartphone app-based intervention, specifically, by helping people prevent the onset of cardiovascular disease and type 2 diabetes mellitus.  

Electronic shared care plan for long term care of cancer patients

A feasibility study to develop and determine how best to engage GPs and patients in a cancer shared e-care plan and assess how specialists, GPs and patients use the e-care planA feasibility study to develop and determine how best to engage GPs and patients in a cancer shared e-care plan and assess how specialists, GPs and patients use the e-care plan

Implementation of a decision support triage tool in specialist-general practitioner shared care

This study will guide the implementation of the shared care team model by evaluating a decision support triage tool that will assist in the selection of patient scenarios at ‘low-intermediate risk’ of complications for shared care, further refine the roles of cancer specialists and GPs, and inform the development of supporting resources.

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. 




Advance Care Planning in Australian Primary Care

This study explores the key stakeholders, general practitioners and patients' views on how Advance Care Planning is currently conceptualised and implemented.

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.




No projects found.