Chronic disease

Funding primary care services for people living with chronic disease including diabetes education, dietetics, podiatry and chronic disease nursing

Man with chronic disease testing blood sugar levels at home

The Murray PHN Needs Assessment identified chronic disease as a key priority for communities across the Murray PHN region. Evidence shows that service coordination and integration are vital to achieving positive health outcomes for people with chronic conditions, who often require healthcare from multiple providers. Challenges in navigating local and broader health systems have also been identified for consumers with complex care needs.

In 2025, Murray PHN completed an evaluation of its long running Chronic Disease Management (CDM) Program. The CDM Program had been focused on delivering allied health services across the catchment to support people diagnosed with priority chronic diseases – diabetes, chronic obstructive pulmonary disease (COPD) and chronic heart failure. From that evaluation came recommendations to further target the available funding to areas of greatest need, and to implement a navigation service to assist consumers living with these complex and chronic diseases in navigating the healthcare system.

Subsequently, Murray PHN developed the Health Connection and Chronic Condition Management Program (HCCCM) to provide ongoing clinical support in local government areas (LGAs) where prevalence and hospitalisation rates for priority chronic conditions remains high, and four regional navigation roles to support people to navigate the health system and services.

The HCCCM model was commissioned in early 2026 and starts on 1 July 2026. There may not always be a like for like replacement of previous CDM services, as new models of care have been developed to better address chronic conditions health needs.

HCCCM Model


The HCCCM program has two coordinated components, both to be delivered in specified local government areas (LGAs):

  • Direct clinical services – individual and/or group interventions delivered in person and/or via telehealth for consumers with COPD, diabetes and/or chronic heart failure. Clinical services include dietetics, podiatry, diabetes education, chronic disease nursing, cardiac and pulmonary exercise groups. To ensure availability, services have been capped at up to six individual occasions of service and up to eight group sessions per consumer (allocation based on need and goals identified during initial assessment).
  • Non-clinical services – Regional Health Navigator (RHN) services – place-based navigation and support across Central Victoria, Goulburn Valley, North East and North West sub-regions of the Murray PHN catchment to help consumers who face significant barriers to accessing and engaging with relevant health services. The RHN will work with individuals and assist them to navigate the health and social system to engage or remain engaged in required services. RHN services are not capped.

The HCCCM program will continue to work closely with the multicultural Health System Navigation program which assists local refugee communities to access health services and supports needed for client-centred care of complex chronic diseases.

Murray PHN funds 12 providers to deliver place-based and outreach HCCCM primary care services, supported by digital modes as appropriate.

Chronic disease resources

Contact us

For more information, e: HCCCM@murayphn.org.au

Last Update: July 6th, 2026

Murray PHN acknowledges its catchment crosses over many unceded First Nations Countries, following the Dhelkunya Yaluk (Healing River).

We pay our respects and give thanks to the Ancestors, Elders and Young people for their nurturing, protection and caregiving of these sacred lands and waterways, acknowledging their continuing cultural, spiritual and educational practices.

We are grateful for the sharing of Country and the renewal that Country gives us. We acknowledge and express our sorrow that this sharing has come at a personal, spiritual and cultural cost to the wellbeing of First Nations peoples. We commit to addressing the injustices of colonisation across our catchment, and to listening to the wisdom of First Nations communities who hold the knowledge to enable healing. We extend that respect to all Aboriginal and Torres Strait Islander peoples.