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.




Diabetes and cardiovascular disease quality improvement

This report depicts the contribution of primary care to the management of diabetes and cardiovascular disease (CVD).

Diabetes prevention

This study aims to determine within general practice and associated services the feasibility, requirements, barriers and benefits/harms for an intervention to detect impaired glucose tolerance and impaired fasting glycaemia and to provide physical activity and nutrition interventions which aim to reduce the risk of type 2 diabetes in this group.

Diagnosing obstructive sleep apnea in primary care

This project is aimed to simplify the method for diagnosing obstructive sleep apnea (OSA) in the primary care setting.

Do patient attitudes contribute to frequent readmissions?

This study determines the characteristics which differentiate frequently readmitted chronic disease patients from those self-managing

Evaluation of Moving On: a self management program for people with a chronic illness

Support for Chronic Disease Self Management (CDSM) is a recognized part of chronic disease management. Arthritis NSW developed Moving On and commissioned CPHCE to evaluate the program.




No projects found.