Chronic disease

This page is for primary care health professionals working in the Brisbane South PHN region, who require support for patients living with chronic disease.

Our dedicated Optimal Care team is your best point of contact for information and links to resources to optimise the management of patients with chronic conditions.

Below is a summary of resources and links to assist primary care to achieve optimal chronic disease care.

Optimal Care Program

The Brisbane South PHN supports general practice to provide ‘Optimal Care’ to people with chronic disease through quality improvement initiatives.

The Optimal Care program assists General practice staff to identify areas in their chronic disease management that they would like to improve or make changes for the benefit of patients and the practice.  This support occurs through the provision of resources and workbooks, and Optimal Care Program Support Officers, who assist practices to implement the quality improvement initiatives.

Optimal Care provides the following support:

  • Advanced training in the use of the PenCS patient data extraction system for chronic disease management
  • Improved practice data quality and analysis for quality improvement
  • Understanding of chronic disease and prevention related MBS item numbers including PIPs
  • Best practice guidelines and clinical decision support tools
  • The use of screening tools e.g. diabetes risk assessment tool (AUSDRISK), cardiovascular risk calculator
  • Coordinating patient care through the use of SpotonHealth Healthpathways

General practices will receive:

  • Support and education from the Optimal Care team via different methods (face-to-face, phone support, in-practice education and group events)
  • Monthly practice data reports sent straight to your inbox
  • Disease specific program workbooks to help guide you through your quality improvement
  • In-practice upskilling from specialist clinicians (eg respiratory educator)

Click here for the Optimal Care program fact sheet.

For further information or to arrange for an Optimal Care Program Support Officer to visit your practice email or phone 3864 7551.

General information on chronic disease

Referral templates

Please click here for information on:

  • Metro South Central Referral Hub
  • referring to local hospitals
  • Metro South Palliative Care service
  • downloadable electronic templates for Medical Director or Best Practice software.



CDM Medicare Benefits Schedule items

Medicare Benefits Schedule (MBS) items make it easier for GPs and practice nurses to manage the healthcare of patients with chronic medical conditions, including those patients who need multi-disciplinary care. GPs can claim from Medicare for coordinating team care planning and review services. Patients with GP Management Plans and Team Care Arrangements can access a maximum of five allied health services per calendar year.

GPMP examples

Useful links and resources

My health for life
My health for life (MH4L) is a free, evidence-based behaviour modification program for patients at high-risk of developing chronic disease. It is a practical extension of the advice given by GPs and practice nurses to their patients; allowing participants to better understand their lifestyle risks and action their health goals.



The program includes six sessions over six months, with ongoing maintenance after the program has finished. Both phone coaching and face-to-face group programs are available, delivered by qualified health professionals who have been trained as MH4L facilitators.

Practices will be kept informed of their patient’s progress with letters sent via secure messaging when the patient has enrolled in the program, and once they have completed the program (or if they withdraw).

For more information about the program content please visit the website.

Through MH4L, Brisbane South PHN can support your practice in the following ways:

  • providing MH4L health professional and patient resources
  • up-skilling staff via in-practice education
  • identifying ways to incorporate the promotion of the program into existing business
  • in-practice strategies to increase patient risk assessments and establish early intervention practices as part of routine clinical care
  • identifying patients that are automatically eligible for the program (pre-existing conditions)
  • identifying patients that are at risk of chronic disease and/or eligible for a health assessment that may be eligible for referral e.g. via Pen CAT4 or medical software searches
  • practice Nurses involved in the Practice Nurse Support Program will benefit from in-depth understanding of risk assessments and prevention activities
  • practices involved in the Optimal Care or Building Digital Health programs can incorporate MH4L into quality improvement activities.

How to refer

Check the patient eligibility flowchart and download electronic referral templates here:

GP referrals are sent to the MH4L team at Diabetes Queensland via Medical Objects or fax 07 3506 0909.

Although GP referral is recommended, referrals can also be made by a practice nurse, allied health professional or the patient themselves by contacting 13 RISK or visiting the website to complete a health check.

Patients that self-refer into the program will require GP consent if they:

  • are pregnant
  • have a mental health issue
  • have a current acute illness (i.e. cancer)
  • have had surgery within the last 12 months
  • have high blood pressure either >160 systolic or >100 diastolic



Chronic respiratory disease resources
Chronic cardiac disease resources

Chronic cardiac disease guidelines

Chronic heart failure guidelines

Acute coronary syndromes guidelines:

Acute rheumatic fever and acute rheumatic heart disease guidelines:

The Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (2nd edition)

A guide to managing hypertension:

A guide to lipid management:

Tools to manage chronic cardiac disease

Chronic Heart Failure

HEART online

Chronic cardiac disease education

Useful links

Obesity and lifestyle resources

Obesity and lifestyle guidelines

Health assessments

Department of Health Medicare Health Assessments Resource Kit

There are additional referral options within the local community for your clients to access chronic disease self-management programs.

Healthy lifestyle and chronic disease management: Patient support options

  • Anglicare offers a generic Chronic Disease Self-Management Program across Southern Queensland. A small co-payment fee will be charged for the program. Further information can be found on their website. Please contact Anglicare via 1300 610 610 for further information.
  • Metro South Health offers a Community of Interest Group. Becoming a member is free of charge and patients will receive access to monthly workshops and newsletters around relevant health topics. For further information please visit their website or contact Tamara Swanton via 3156 4977.

Obesity and lifestyle education

Useful links