Patient self-management

Chronic disease self-management (CDSM) is central to Australia’s national strategic policy approach to chronic disease prevention and management. The CDSM approach emphasises patient-centred care and behaviour change support, and optimises the delivery of collaborative care.

Lifestyle change is difficult.  Even amongst patients who initiate changes, longterm maintenance of new health behaviours is rare. With funding from Australian Rotary Health, we developed the Beating Heart Problems program based on the CDSM model, using principles of motivational interviewing and cognitive behaviour therapy. This 8-session modulated program addressed physical activity, dietary change, smoking cessation, and medication adherence, depression, anxiety, anger and social isolation. A randomised controlled trial of the intervention involving 275 cardiac patients demonstrated substantial improvements in physiological, behavioural and psychosocial risk factors over usual care.

Recent Australian audits show that many health professionals lack the knowledge and/or skills to incorporate CDSM into practice. Targeted training of CR professionals is required to support the integration of a CDSM approach within CR programs. With funding from the Commonwealth Department of Health and Ageing, we developed a face-to-face training program for health professionals based on CDSM principles.

We have also developed a telephone program, titled Teleheart, and an online program, titled Back on Track, both designed to support cardiac patients in their emotional and behaviour recovery.  Both are extensions of our successful Beating Heart Problems group program for patients. We have also developed a health professional online program – Supporting chronic disease self-management – an extension of our original group training for health professionals.

‘Back on Track': An online secondary prevention program for cardiac patients

Many cardiac patients want home-based alternatives to centre-based support programs such as cardiac rehabilitation. 'Back on Track' is an internet-delivered self-management program for cardiac patients and companion to the successful 'Beating Heart Problems' program.

Read More »


‘Teleheart’: Developing and piloting a telephone-delivered secondary prevention program

To complement the group-based Beating Heart Problems Program and the internet-delivered Help Yourself Online, we have recently developed a telephone-delivered version of the program – Teleheart. We are currently trialing the program with patients at Southern Health.

Read More »


HRC Network: Connecting health professionals for improved practice

The newly-formed HRC Network is an exciting project that aims to connect health professionals across Victoria and improve their skills in chronic disease self-management.

Read More »