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This was an innovation project supported by the Better Care Victoria Innovation Fund.

Lead organisations

  • Western Health
  • Western Health Chronic Disease Alliance (WHCDA)


  • Former Macedon Ranges and North Western Melbourne Medicare Local
  • North Western Melbourne Primary Health Network
  • Murray Primary Health Network
  • Stroke Foundation
  • Heart Foundation
  • Diabetes Victoria
  • Kidney Health Australia
  • University of Melbourne
  • Victoria University
  • PEN Computer Systems


Chronic disease is a major cause of death and disability in Australia and accounts for 35 per cent of the country’s healthcare spending. The significant cost of chronic disease is particularly pronounced in northwest Melbourne due to a growing population with lower socioeconomic status, higher rates of chronic disease, and lower uptake of private healthcare insurance. 

These factors place a significant strain on the hospital services at Western Health, leading to long outpatient clinic wait lists, and increasingly complex and expensive hospital admissions. 

Western Health worked with general practitioners (GPs) to proactively stem the burden of chronic disease, trialling an e-technology program that not only helped to manage diagnosed chronic disease but also to improve its early detection, with the aim of preventing or delaying disease progression and complications.


Improve the detection and management of patients presenting to GPs who are at risk of developing chronic kidney disease, cardiovascular disease and type 2 diabetes or who already have one of these diseases.


  • Improved the detection and management of patients with chronic disease during the initial 15-month program, potentially reducing disease progression and complications
  • Sustained improvements in the detection and management of chronic disease 27 months after program commencement


December 2020 – The results of the program at 15 months and 27 months following intervention for the initial practices have been presented at international conferences, including the European Renal Association – European Dialysis and Transplantation Association Congress, with abstracts published in Nephrology Dialysis Transplantation. 

The learnings from CD IMPACT are also being used to develop the Future Health Today program, a less human resource intensive and potentially scalable e-technology tool that helps improve the detection and management of chronic disease in general practice. 

Project summary

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