The Program

The Integrated Chronic Disease Care (ICDC) program partners with General Practitioners (GPs) and provides care coordination and multidisciplinary healthcare for people who have diabetes, cardiovascular or respiratory conditions and need help to access services.

Whether you have just been diagnosed or have been living with your illness for some time the ICDC program provides free, individualised, comprehensive and coordinated services and support so you can better self-manage and meet the care needs of your condition and improve your health and quality of life.

Self-management is the day-to-day management of a chronic disease by the individual over the course of their illness1. Self-management requires people to have good communication, problem and decision making skills and the ability to find and use resources in their community. The ICDC program can help you develop self-management skills so you can:

  • Deal with symptoms and effects of your illness.
  • Monitor your health (e.g., understand and take blood pressure or blood sugar readings).
  • Follow a healthy diet and participate in physical activity.
  • Make difficult lifestyle changes and adjust to psychological and social demands.
  • Engage in effective interactions with health care providers.

1.  Grady, P., Gough L. (2014) Self-Management: A Comprehensive Approach to Management of Chronic Conditions. Am J Public Health, 104(8): e25-e31.



To be eligible for the program, clients must be medically diagnosed with diabetes, chronic heart disease or a chronic respiratory illness and have limited access to multidisciplinary care from allied and other health professionals due to:

  • Financial barriers e.g., Health Care or Pension Card.
  • Geographical barriers (live >100km from Geraldton).
  • Social or cultural barriers.
  • Exhausting Medicare Chronic Disease Allied Health visits.
  • Health or medical barriers.
  • Transport or physical access limitations.

All clients accessing the ICDC program must have a GP referral that includes a GP Management Care Plan. People with a chronic disease who would like to access the program, but do not have a regular GP or care plan and referral, should contact their area’s care coordinator, if they need help to do this.

My Health Record

Clients of ICDC are encouraged to have a My Health Record, which is an online summary of your health information that both patients and health professionals can add health information too. By the end of 2018, unless you choose not to have one, a My Health Record will be created for every Australian.

This tool helps the ICDC service providers share information about the care that you receive and work together with you to meet your health goals. For more information head to the My Health Record website



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