Integrated Chronic Disease Management

The Integrated Chronic Disease Management (ICDM) program aims to improve the quality of life of people and their Carers with chronic and complex conditions such as COPD, coronary heart disease, chronic heart failure and diabetes.

ICDM provides care coordination, case management and health coaching.

Our program can provide education aimed at improving the self-management of clients chronic diseases to help them learn more about their illness and to assist in better managing their health condition.

Contact

345 Pacific Hwy
Coffs Harbour NSW 2450

Referral criteria

  • Documented diagnosis of cardiovascular disease, COPD, diabetes or congestive heart failure.
  • Likely compliance to a developed care plan.
  • Reside in area of coverage.
  • Age >18yrs or Aboriginal and Torres Strait Islander Age >16 AND
  • Have one UNPLANNED admission in the past 12 months with one of the
    chronic DRG’s OR
  • Three or more unplanned admissions in a 12 month period with one of the chronic diseases as either the principle or additional diagnosis.

    Exclusion criteria apply for this service.

Referral criteria

  • Documented diagnosis of cardiovascular disease, COPD, diabetes or congestive heart failure.
  • Likely compliance to a developed care plan.
  • Reside in area of coverage.
  • Age >18yrs or Aboriginal and Torres Strait Islander Age >16 AND
  • Have one UNPLANNED admission in the past 12 months with one of the
    chronic DRG’s OR
  • Three or more unplanned admissions in a 12 month period with one of the chronic diseases as either the principle or additional diagnosis.

    Exclusion criteria apply for this service.

Referral criteria

  • Documented diagnosis of cardiovascular disease, COPD, diabetes or congestive heart failure.
  • Likely compliance to a developed care plan.
  • Reside in area of coverage.
  • Age >18yrs or Aboriginal and Torres Strait Islander Age >16 AND
  • Have one UNPLANNED admission in the past 12 months with one of the
    chronic DRG’s OR
  • Three or more unplanned admissions in a 12 month period with one of the chronic diseases as either the principle or additional diagnosis.

    Exclusion criteria apply for this service.

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