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. 



No projects found.




Systematic review of chronic disease management in primary care

This review focussed on those chronic diseases most commonly managed in primary care. The review was informed by the Chronic Care Model proposed by Wagner and colleagues which includes the six dimensions of organisation of health care, delivery system design, decision support, self management support and community resources.

Systematic Review of Effective Determinants for Supporting Lifestyle Health Literacy in Primary Health Care (APHCRI)

This was a systematic review of the literature on effective interventions and drivers for health literacy in relation to the SNAP risk factors in primary health care, and the implications for practice and policy

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.  

Team-link study: AHMAC outcomes of multidisciplinary care in general practice

This study explores whether improvements in teamwork between general practitioners and referral services lead to improved patient outcomes.

Teamwork: Enhancing the role of non GP staff in Chronic Disease Management in General Practice

The aim of this study is to examine the extent to which quality of care for patients with cardiovascular disease and diabetes can be increased through a structured intervention involving practice managers, receptionists and nurses.




No projects found.