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Chronic Disease Care and Support

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What is a chronic disease?

A Chronic Disease is any illness that is long term, lasting more than six months and requires ongoing management. Chronic diseases may include diabetes, heart disease, high blood pressure or a long term breathing problem like chronic obstructive pulmonary disease (COPD).

Chronic Disease Care and Support Services may include the following:

  • Chronic disease management and support
  • Health care for pre-existing or long term illness
  • Diabetes education and dietary support
  • Cardiac care and rehabilitation
  • Dementia Services
  • Palliative Care
  • Respiratory Care and Pulmonary rehabilitation

Chronic Disease Management and Support

MLHD can help you better manage your health conditions and avoid hospital by:

  • providing extra support in your home to help with your health and other needs
  • coordinating services to get the right care you need
  • providing the education and tools to assist you to manage and understand your chronic condition

Our team of health workers work with your current services and support network, including your GP to design your care program, with clinical and social services tailored to your needs.


Contact the Integrated Care Team Leader on 02 5908 4112 or email: summa.stephens@gsahs.health.nsw.gov.au

For more information click here to download the Chronic Disease Management Program brochure

Services available

Diabetes Education and Dietary Support

Diabetes Education is an interactive process that facilitates and supports the individual, their family and/or carer to acquire and apply the knowledge, confidence, practical problem-solving and coping skills needed to manage their life with diabetes. Diabetes Education aims to achieve the best possible outcomes within the persons own unique circumstances.

Become better informed about Diabetes Self-Care by visiting a free confidential diabetes education service at your local Community Health Service where we can assist with:

  • Gestational Diabetes (Diabetes in Pregnancy)
  • Type 1 Diabetes
  • Type 2 Diabetes
  • Impaired Fasting Glucose or Impaired Glucose Tolerance

The Diabetes Educator and Dietitian will individualise your education and work with you to achieve diabetes self-care management using the Australian Diabetes Educators Association 7 steps to success:

  • Healthy eating
  • Being Active
  • Monitoring
  • Taking Medication
  • Problem solving
  • Healthy Coping
  • Reducing Risks

MLHD Diabetes Educators are based at Corowa, Deniliquin, Finley, Griffith, Junee, Leeton, Narrandera, Wagga Wagga and Young. The services are also offered at outreach sites across the health district. To access MLHD Diabetes Education contact your local community health service.

Cardiac Care and Rehabilitation

Support is available for people who have a heart condition or when recovering from a medical procedure for the heart. Individuals and family members may benefit from the information provided by a nurse who specialises in supporting people with heart conditions.

In MLHD Cardiac Care Coordinators are based in the larger hospitals. Chronic Care Coordinators and Nurse Practitioners specialising in both Cardiac and Respiratory Care provide services across the health district. All offer cardiac rehabilitation programs aimed at improving management of heart conditions. Cardiac rehabilitation can be offered as a group program supported by a team of health professionals to facilitate and support recovery. Cardiac Rehabilitation can also be offered as a home based program.

Cardiac Rehabilitation broadly aims to:

  • Maximise physical, psychological and social functioning to enable people with heart disease to lead fulfilling lives with confidence.
  • Introduce and encourage behaviours that may minimise the risk of further heart events and conditions.

Cardiac Rehabilitation is offered at a range of sites across the health district including: Wagga Wagga, Albury, Cootamundra, Corowa, Deniliquin, Finley, Griffith, Hay, Hillston, Leeton, Narrandera, Temora, Tumut and Young.

Contact your Health Service for local details.

Respiratory Care and Pulmonary Rehabilitation

If you have a lung condition such as Chronic Obstructive Pulmonary Disease (COPD), ie Emphysema, or Asthma you may benefit from assistance to manage your care.

Respiratory Care Coordinators and Asthma Educators can assess your needs and provide specific information for managing your lung condition, including education for symptom recognition, management and action.

MLHD provides specific programs for people with chronic lung conditions. Pulmonary Rehabilitation programs provide information on lung function and managing lung conditions.

The programs include exercise sessions prescribed by physiotherapists to improve your exercise capacity & improve mobility, and manage breathlessness.

Pulmonary Rehabilitation programs are offered at: Albury, Cootamundra, Corowa, Deniliquin, Griffith, Hay, Hillston, Leeton, Narrandera, Temora, Tumut, Wagga Wagga & Young.

For information on your closest Respiratory Care service contact your local Health Service.

Palliative Care

Palliative Care services work in partnership with local health workers and carers to facilitate people to receive quality care at the end of life. Care is provided as close to home and in the setting of the person’s choice, whenever possible.

Palliative care is not restricted to the terminal stages of an illness but is provided based on the individual’s level of need. People who have cancer, late stage chronic illness such as lung, heart or kidney disease, or dementia may require a palliative approach to ensure comfort as their illness progresses.

Palliative care:

  • provides relief from pain and other symptoms
  • offers a support system to help people live as actively as possible until death
  • offers support to help the family cope during the person’s illness and in their own bereavement
  • uses a team approach to address the needs of the person and family
  • will enhance quality of life
  • is suitable early in the course of illness, in conjunction with other therapies such as chemotherapy or radiation therapy.

MLHD Specialist Palliative Care Services are based at Wagga Wagga, Albury, Deniliquin, Griffith & Young. Some people will not require a specialist palliative care service and will be successfully cared for by local services. However, if symptoms become unstable or there are other unresolved issues a referral to a specialist palliative care service will be recommended.

For details contact your local Health Service or talk to your General Practitioner.

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This web page is managed and authorised by Web Services Development of the NSW Department of Health. Last updated: 5 March, 2012