Chronic Disease Management Plans: A Brief Study Based Tech View

If you've got a chronic medical condition, you'll be eligible for up to 5 rebated sessions with allied health care visits under a Chronic Disease Management Referral (previously known as an EPC or Enhanced Primary Care plan).

Some samples of conditions which are likely to be covered with a Chronic Disease Management referral are:

  • Chronic musculoskeletal conditions
  • Asthma
  • Cancer
  • Cardiovascular disease
  • Diabetes (type 1 & 2)
  • Kidney disease
  • Stroke

The objective of our study was to examine various existing chronic disease models, their elements and their role within the management of Diabetes, Chronic Obstructive Pulmonary Disease (COPD), and Cardiovascular diseases (CVD).


A literature research was performed by using PubMed and CINAHL during a period of January 2003 to  March 2011. Following key terms were used either in single or together such as Chronic Disease Model and Diabetes Mellitus or (COPD) or (CVD).


A total of 23 studies were included in the final examination. Majority of the studies were US-based. Five chronic disease models included Chronic Care Model (CCM), Improving Chronic Illness Care , and Innovative look after Chronic Conditions (ICCC), Stanford Model (SM) and Community based Transition Model (CBTM). CCM was the foremost studied model. Elements studied included delivery system design and self-management support (87%), clinical data system and decision support (57%) and health system organization (52%).

Elements including center care on the patient and family (13%), patient safety (4%), community policies (4%), integrated health care (4%) and remote patient monitoring (4%) haven't been well studied. Other components including support pattern shift, manage political environment, align sectoral policies for health, use health-care personnel more effectively, support patients in their communities, emphasize prevention, identify patient particular  concerns associated with the transition process, and health literacy between visits and coverings have also not been well studied in the existing literature.


It was undecided to what extent the results generated are applicable to different populations and locations and therefore is an area of future study. Future studies also are needed to test chronic disease models in settings where more racially and ethnically representative patients receive chronic care. 

Future program development should also consist of information on other barriers including transportation issues, finances and deficiency of services.

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