Early Intervention and Integrated Care occurs when health services work with clients and their carers to provide a coordinated, seamless and integrated approach to deliver responsive and person centered care.

Hume Whittlesea Primary Care Partnership provides capacity building to support agencies to deliver an integrated approach to chronic disease service delivery. It does so by facilitating clinical practice improvement initiatives, strengthening community action and workforce development.

The Department of Health and Human Services produces a range of resources and supporting documents to support agencies implement a systems improvement approach in the early intervention and management of clients who present with chronic and complex care needs. Visit the Department's Integrated chronic disease management resources page.


MOVE (formerly Arthritis Victoria) Information Pack for PCP Members.

Diabetes Australia Online Information for Mental Health Staff.

The aim of the Care for people with chronic conditions guide is to ensure chronic care services provided by the Community Health Program improve the health and wellbeing of people with chronic conditions. 

A place where younger people with dementia, their families, carers and friends can gather and share information

Arthritis Victoria

Advocate, educate and provide information on Chronic Fatigue Syndrome.


Guidelines and Toolkits

Practical resources and tools relevant to disease management services


Goal Directed Care Planning

Heart Education Assessment and Rehabilitation Toolkit (HEART) Online

Chronic heart failure resources for health professionals

Victorian public health and wellbeing outcomes framework and data dictionary

CC-TNA Picture

Assess knowledge and skills relating to the provision of chronic care.


Train Peer Leaders to provide on-going diabetes self-management support as part of a larger study.


Innovative Care for Chronic Conditions: Building Blocks for Action

Obesity in Primary Care

This summary guide contains information on how to assess & manage overweight & obesity in adults, adolescents & children

Strengthening the System - A partnership approach to chronic disease prevention.

Heart Health is the sequential report to the policy roadmap Getting Australia’s Health on Track and outlines a national implementation strategy for the heart health policy. This report has been compiled by a national collaboration of leading chronic disease experts and clinicians.




The Australian Diabetes, Obesity & Lifestyle Study 2012


PHCRIS Policy Issue Review: The role of primary health care in primary and secondary prevention of diabetes

Deaths among people with diabetes in Australia 2009-2014

Preventing Chronic Disease - How Does Australia Score?A scorecard on the implementation of WHO recommended
interventions to reduce preventable chronic disease.

Australian Institute of Health and Welfare. A picture of overweight and obesity in Australia (2017)

Australian Institute of Health and Welfare. Overweight and obesity in Australia: a birth cohort analysis

RES - Beyondbushfires

Australia’s Health Tracker by Area is an interactive website that provides the most up to date Australian data on chronic diseases, conditions and their risk factors.