Chronic Disease Management Alliance

The Chronic Disease Management Alliance was established in response to the local population health data indicating a high and increasing prevalence of chronic disease across the catchment and the associated burden on our local health system. Our primary health care system must be able to respond in an appropriate and cost effective way to this challenge, focussing resources and collaborative action on prevention, early detection and proactive management of chronic disease.


That all people with chronic diseases within the Frankston Mornington Peninsula catchment will be engaged in high quality, coordinated and person-centred health care that supports them to achieve optimal health outcomes throughout their lifetime.


The Chronic Disease Management Alliance has three overarching goals:

  1. Reduce avoidable hospital admissions
  2. Improve the quality of life for people with chronic disease
  3. Reduce the incidence and prevalence of chronic disease

Action Areas

  • Promoting healthy lifestyles and environments for individuals and communities across the life course
  • Supporting the early detection of chronic disease and its risk factors including early intervention and lifestyle and risk factor modification programs
  • Integrated management and targeted clinical care for people with chronic disease
  • Supporting active patient self-management for people with chronic disease
  • Improving communication and coordination between service providers
  • Enabling our workforce to support people with chronic disease and their carers/family
  • Strengthening monitoring, surveillance, research and evaluation

Key Projects and Strategies

Many of the strategies within the CDM Alliance are population focused applications of key projects that involve multiple Peninsula Model Alliances and sectors.

  1. Health Literacy – participation in the Peninsula Model Health Literacy Initiative which aims to support consumers to obtain and understand health information, to access appropriate services, and to be actively engaged in their health care.
  2. Self Management support – to improve the quality and reach of self management support services within CDM services in the catchment
  3. Technology initiatives – to actively engage in and support implementation of the secure messaging and care pathways projects, and to support new technology opportunities that improve consumer health outcomes
  4. Service system improvements – improve screening, early identification, care planning, and communication through implementation of the DHHS standards for Best Practice in Service Coordination within CDM Services


The current membership of the Chronic Disease Management Alliance and working groups includes representation from the following organisations working across the Frankston Mornington Peninsula

  • Frankston Mornington Peninsula Primary Care Partnership
  • Peninsula Health – acute, subacute and community health
  • Mornington Peninsula Shire
  • Frankston City Council
  • South Eastern Melbourne Primary Health Network
  • St John of God Frankston Rehabilitation Hospital
  • Consumer representative
  • Cranbourne Road Medical Centre
  • The Sports Injury Clinic
  • Health Information Consultancy
  • PACE health Management
  • ActiveOne


For any further information about the Chronic Disease Management Alliance, it's areas of work or membership, please contact Dianne Berryman, Integrated Care Coordinator, Frankston Mornington Peninsula Primary Care Partnership on 9788 1544 or email

Chronic Disease Management Alliance Terms of Reference