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.




Review Lifescripts Demonstration Divisions Program

During 2007-2008, AGDHA has funded ten Divisions of General Practice to participate in the Lifescripts Demonstration Divisions project. The participating Divisions will each implement different models of Lifescripts with a minimum of five practices. This study uses a mixed method approach to develop typologies and identify factors which acted as facilitators and barriers.

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.

Scoping paper on barriers and enablers to using diabetes care items

Take up of Chronic Disease items has been patchy. This paper attempts to show why from a practice perspective.

Scoping paper on evidence based interventions for diabetes mapped against national policies and programs

This study aims to identify evidence based interventions in diabetes prevention, detection, management and consumer support.

Scoping paper to examine the uses of and costs of a network of general practices to monitor changes in chronic disease care

This paper will assess the full range of costs and benefits which might arise from having access to current information about changes in patterns of chronic disease care from a general pratice perspective




No projects found.