Rehabilitation for Chronic Disease Model of Care
Chronic diseases, while not immediately life-threatening, are the most common and leading cause of premature mortality. People who experieince a chronic disease need timely access to appropriate diagnosis with rapid referral to chronic disease rehabilitation services. These services assist people with a chronic disease to achieve optimal physical and psychological function, to self manage their disease and to be active partners with their medical team in decisions about their health care. The key principles of chronic disease rehabilitation are early and accurate diagnosis as well as education and rehabilitation. Successful rehabilitation services have five key elements:
- easy and early access to services
- comprehensive assessment
- holistic goal setting
- individually designed, multidisciplinary interventions
- links to maintenance and support.
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| Bethany is 46 and has a history of smoking and asthma. Bethany is getting breathless, has a cough and is very weak. | She visits her GP who sends her for tests such as spirometry. She is diagnosed with COPD. | Bethany and her GP prepare a care plan. | Bethany is referred to the Rehabilitation Service for a comprehensive assessment. | The service includes pulmonary rehabilitation and smoking cessation, and counselling for Bethany and her partner. | 8 weeks post rehabilitation Bethany returns to work. | She receives regular support and maintenance from the Rehabilitation Service. |  |
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About the Rehabilitation for Chronic Disease Model of Care
Implementation - guide on how to implement this Model of Care
- Guidelines, Tools and Hints to help implement this model.
Download a printable version of the Model of Care - PDF 
Literature - that supports the Model of Care
- View references used to develop the Model of Care.
Contact - to find out more about this model
Principal Project Officer, Integrated Aged and Chronic Care
Health Services Performance Improvement Branch, NSW Health
Phone: 02 9391 9832
