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.




Telephone coaching models to support chronic disease management in multi-morbid and vulnerable populations: a rapid review (Sax Institute)

This rapid systematic review was commissioned by NSW Ministry of Health, working with the Sax Institute. The review will inform thinking about a possible state wide telephone coaching service for people who are, or at risk of becoming, high users of the hospital system for the management of their chronic conditions.

The collaborative care planning scale: A new measure of shared decision making in chronic illness care

This study will use standard psychometric techniques to ensure that the CCPS is a reliable and valid scale for use in studies of interventions to improve the health outcomes of people with chronic and complex illnesses.

The feasibility and impact of cardiovascular absolute risk assessment in Australian general practice

Investigation of the feasibility of CVAR implementation in Australian general practices and the impact of CVAR assessment and management has on several factors.

Torpedo study: cardiovascular risk assessment and management in primary care

RCT of a decision support tool for the assessment of absolute cardiovascular risk in general practice.

Trial of SNAP in two divisions of general practice

Evaluation of the capacity of Divisions of General Practice in collaboration with other services to support general practice to improve the frequency and quality of their interventions to change SNAP risk factors.




No projects found.