Support to
encourage change


CareFirst is a behaviour change program that supports patients to proactively manage their chronic condition.

Focus on five chronic diseases

CareFirst is for patients diagnosed with one of the following chronic conditions:

Chronic Heart Failure

Who can participate?

A GP Liaison Officer works with GPs and practice staff to identify which patients are eligible for the program.

Once a CareFirst patient is enrolled, an initial appointment for a face-to-face assessment is scheduled to develop their CareFirst plan.

Support services

CareFirst offers extensive evidence-based support services to build self-management skills, including:

  • a new or updated care plan for specific conditions, but individualised for their goals and needs
  • a series of health coaching sessions delivered by registered health professionals
  • phone calls from a dedicated Care Navigator to help track healthcare appointments, medication and health goals
  • healthy living and disease specific support resources
  • access to a health advice line.

Program duration

CareFirst runs for six months including a 16-week ‘intensive phase’ which includes a mix of face-to-face coaching visits as well as phone calls from a Care Navigator. The program concludes with a six-month review, and detailed progress report.

GP Practice registration

CareComplete helps build practice capacity to offer evidence-based chronic condition management services.

The programs are designed to enhance existing chronic disease management practices without requiring significant time or investment from clinic staff.

For further information please call the CareComplete team on 1300 650 742

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Case study: Marg

Age: 69 Health details: asthma, coronary heart disease, type 2 diabetes, osteoarthritis, BMI of 37.

“I finally have the right care team around me – I have lost weight and my waist measurement is down. I am very happy!”

Marg’s ultimate goal was to lose weight to be more mobile and healthy.


  • Medication review which led to a new diabetes medication
  • Three consultations with a dietitian
  • Coaching sessions to increase knowledge and confidence in managing her conditions
  • Formal personal training sessions, including organised pool sessions to help with movement related pain
  • Started using an exercise video at home as well
  • Engaged with a physiotherapist, ophthalmologist and podiatrist

The recommendations were discussed with Marg’s GP and implemented by her Care Coordinator. Funding was provided by community services and additional health providers.


  • Lost more than three kilograms
  • Stabilised HBA1C levels (after commencing new diabetes medication)
  • Consistently making healthy food choices and eating smaller portions
  • Increased physical activity to 240 minutes of exercise each week (from zero at baseline), and plans for ongoing activity
  • Risk of hospitalisation (measured by the HARP tool) has dropped from 20 (med-high) to three (low)

Patient’s name and photo have been changed for privacy purposes.

CareFirst is based on the widely adopted Chronic Care Model (also known as the ‘Wagner Model’) developed by the MacColl Center for Healthcare Innovation, which identifies six key elements for improving care of people with chronic illness.1
Six core elements for improving chronic care:1
  1. Stronger links between providers and community-based resources
  2. Prioritising chronic care in the payment structure
  3. Support for patients to develop skills and confidence to manage their condition better
  4. Specialised training for staff to support self-management goals and assist with follow up
  5. A framework based on evidence-based guidelines
  6. Computerised systems to facilitate compliance with guidelines, provide feedback and improve planning for patient care.


This model has informed successful chronic disease management interventions in the US, UK and Australia.2,3 CareFirst incorporates all six of these core components.

Supporting self-management

Additional evidence supports the use of self-management strategies that are central to CareFirst. An analysis of 29 international trials including over 5,000 patients found that chronic disease management programs that systematically used evidence-based guidelines, self-management strategies and multidisciplinary care reduced hospitalisation by up to 25 per cent in patients with heart failure.4,5 Providing patients with tools, knowledge and support to take control of their condition is key to high-performing chronic care programs.6,7 A systematic review in Australia found that the most effective interventions offered self-management support,including educational sessions and counselling, combined with multidisciplinary teams involving registered health professionals.3


References: 1. Bodenheimer T, et al. Improving primary care for patients with chronic illness: The chronic care model, part 2. JAMA, 2002. 288(15): p. 1909–1914. 2. Singh, D. and C. Ham, Improving care for people with long-term conditions: a review of UK and international frameworks. 2006: University of Birmingham. Health services management centre. 3. Zwar, N., et al. A systematic review of chronic disease management. The University of New South Wales. Australian Primary Health Care Research Institute: Sydney, 2006. 4. Scott IA. Public hospital bed crisis: too few or too misused?, 2010, Aust. Health Review 34, 317–324. 5. McAlister FA, et al. Multidisciplinary strategies for the management of heart failure patients at high risk for admission: A systematic review of randomised trials, 2004, Journal of the American College of Cardiology, Vol 44 (4): 810–819. 6. Coleman, K., et al., Evidence on the Chronic Care Model in the new millennium. Health affairs, 2009. 28(1): p. 75–85. 7. Brown, R.S., et al. Six Features of Medicare Coordinated Care Demonstration Programs That Cut Hospital Admissions of High-Risk Patients. Health Affairs, 2012. 31(6): p. 1156–66.