Skip to Content
 Close search

Innovations in care for chronic health conditions

Commission research paper

The case study was handed to the Council on Federal Financial Relations (CFFR) on 19 March 2021 and publicly released on 24 March 2021.

This is the second report in a series of case studies on productivity reforms across the Australian Federation.

This report is about innovative approaches to managing chronic health conditions. Such initiatives aim to promote people’s wellbeing, increase the efficiency of the healthcare system and reduce hospital use.

The initiatives included in this report offer practical examples of preventive health innovations and provide insights into overcoming entrenched barriers to implementation of health reform.

In March 2021, the CFFR asked the Productivity Commission to prepare a plan for progressing the opportunities for innovation identified in its productivity reform case study. The information paper is the response to that request. The paper was released on 3 November 2021.

Download the case study

Download the information paper

  • At a glance
  • Webinar
  • Contents

Expand allCollapse all

Key points

  • Innovative approaches to managing chronic health conditions are present in all types of health services and in all jurisdictions.
    • These innovations improve people’s wellbeing and reduce the need for intensive forms of health care, such as hospital admissions. They achieve this through improved responsiveness to consumer preferences, greater recognition of the skills of health professionals, effective collaborative practices, better use of data for decision making by clinicians and governments, and new funding models that create incentives for better management or prevention of disease.
    • The case studies of innovation included in this report show that there are practical ways to overcome long-standing barriers to health reform. They enable quality care for people with chronic health conditions and are backed by evidence of better outcomes and greater efficiency. Implementing them more widely, with adaptation to local needs where required, would deliver benefits to consumers, practitioners and governments.
  • There are substantial barriers to the development and broader diffusion of healthcare innovations.
    • Innovation often relies on the commitment of dedicated individuals and the support of local health service executives. But unless there are strong incentives for change, entrenched organisational and clinical cultures tend to maintain the status quo.
    • Existing funding structures, which are largely based on the volume of healthcare services delivered, do not encourage investment in quality improvement. Some trials of innovative approaches are only funded for short periods, making it difficult to achieve outcomes and dampening the willingness of clinicians to participate.
    • There are few structured mechanisms to encourage the diffusion of innovation. Health services often try to solve problems that have been overcome in other places or other parts of the system.
  • Implementing innovative interventions on a larger scale depends on effective diffusion mechanisms and funding reform.
    • There are existing institutions in the health system that could contribute to the diffusion of evidence on quality improvement and support better care for people with chronic conditions.
    • Trials of blended payment models and pooled funding — supported by data and models that ensure interventions assist the people who face the highest risks of avoidable hospitalisation — offer a path towards funding reform.

Media release

Simple innovations for chronic health issues could help millions

Across Australia, innovations in healthcare are improving the lives of people with chronic health conditions such as diabetes and arthritis.

However, while nearly ten million Australians, or around 40% of us, now live with chronic health conditions these successful innovative programs only benefit a small fraction.

“There are many simple and inexpensive innovations that help people avoid hospital and enjoy a better quality of life,” Productivity Commissioner, Stephen King said.

“But these innovations are localised — limited to one state or even one town. People only get access if they live in the right place,” he said.

The report Innovations in care for chronic health conditions by the Productivity Commission highlights examples of services that successfully manage chronic health conditions.

They include initiatives that send friendly SMS reminders to people to monitor their symptoms and make healthy choices, and programs that rearrange health service workflows so they can offer better support.

“While the health system works well for most people, most of the time, its weaknesses are exposed when it comes to chronic health conditions,” Productivity Commissioner Richard Spencer said.

“For example health services in one part of the country may not know what is happening in other areas, so great ideas are only partly adopted,” he said.

Half of all hospital admissions are related to chronic health conditions. One of the programs the report looked at lowered admissions by 25%, by keeping in touch with patients and helping them address problems before they needed hospitalisation.

With relatively small investments, such innovations could be expanded, benefitting more people. Governments have an appetite for change and are making progress but diffusion of new ideas could be much more effective.

“Health system reform is often slow and piecemeal. Our report provides examples of services that found ways to improve care within the system we have now — they offer valuable and practical lessons for other parts of the health system,” Stephen King said.

“If all of the good ideas identified by the report, and some of them were breathtakingly simple, were adopted across Australia, they could benefit millions of Australians,” he said.

The Productivity Commission's report on Innovations in care for chronic health conditions can be found at

The Productivity Commission held a webinar on 14 May 2021 to discuss its productivity reform case study Innovations in Care for Chronic Health Conditions.


Michael Brennan, Productivity Commission Chair (at 0:00)

An introduction the Innovations in Care for Chronic Health Conditions report.

Stephen King, Commissioner (at 5:34)

Key findings from the Innovations in Care for Chronic Health Conditions report.

Dr Kean-Seng Lim (at 19:10)

Dr Kean-Seng Lim is a Mt Druitt GP and a former president of the New South Wales branch of the Australian Medical Association. He spoke about the experience of transforming a GP practice into a patient centred medical home.

Libby Dunstan (at 32:56)

Libby Dunstan is the CEO of the Brisbane North Primary Health Network (PHN). She spoke about sustaining innovation and collaboration from a PHN perspective.

Don Campbell and Keith Stockman (at 48:23)

Don Campbell is the Clinical Service Director, Staying Well Program and Medical Division Director, Hospital Without Walls and Keith Stockman is the Director of Service Design and Innovation, Staying Well Program and Hospital Without Walls.

Don and Keith were involved in the design and implementation of the Monash Watch program, which was featured in the Commission’s report. They are working on a similar program, Patient Watch, at Northern Health.

Don and Keith talked about their experience with, and the barriers and enablers they have faced, adapting the Monash Watch program for Northern Health.

1:02:07 Q&A
  • Cover, Copyright and publication details, Foreword, Abbreviations and Contents
  • Key points
  • Overview
  • Chapter 1 Learning from innovations in care for chronic health conditions
    • 1.1 Chronic conditions are becoming more prevalent and costly
    • 1.2 Australia has had success in preventing ill health, but could do more
    • 1.3 Making the case for preventive health can be a complex exercise
    • 1.4 The contribution and approach of this report
  • Chapter 2 Supporting people to manage their chronic conditions
    • 2.1 Self management of chronic conditions is essential, but it can be hard to achieve
    • 2.2 Simple tools and support can make a big difference
      • Case study 1 — Nellie
      • Case study 2 — Turning Pain into Gain
    • 2.3 Supporting people on their terms
      • Case study 3 — One Stop Liver Shop
      • Case study 4 — Monash Watch
    • 2.4 Supporting self management is one step towards strengthening consumer partnerships
  • Chapter 3 Empowering the health workforce to deliver better outcomes
    • 3.1 Drawing on many professionals’ skills in care teams
      • Case study 5 — WentWest’s General Practice Pharmacist program
    • 3.2 Supporting GPs to provide more complex care
      • Case study 6 — Sunshine Coast’s GPwSI model of care
    • 3.3 Developing peer support roles to improve the consumer experience
      • Case study 7 — Choices
    • 3.4 Growing the Indigenous health workforce
  • Chapter 4 Building and sustaining collaboration
    •       Case study 8 — Western Sydney’s COVID –19 response
    • 4.1 Helping workers collaborate in a systematic way
      • Case study 9 — Royal Perth Hospital Homeless Team
    • 4.2 How leaders and managers support collaboration
      • Case study 10 — The Collaborative
    • 4.3 Using opportunities to fund collaboration
  • Chapter 5 Improving the flow and use of information across the health system
    • 5.1 Barriers to using data in the health system
    • 5.2 Making the most of consumer information within primary care
      • Case study 11 — Primary Sense
      • Case study 12 — Chronic Conditions Management Model
    • 5.3 Improving information flows between primary and acute care
      • Case study 13 — Smart Referrals
    • 5.4 Better data linkage can offer insights to consumers, practitioners and policy makers
      • Case study 14 — Lumos
  • Chapter 6 Embracing funding innovations
    • 6.1 Overview of funding arrangements
    • 6.2 Current funding arrangements can lead to poor outcomes
    • 6.3 Making the most of the current arrangements
      • Case study 15 — Institute for Urban Indigenous Health
    • 6.4 Pooling funding to deliver integrated care
      • Case study 16 — Collaborative Commissioning
    • 6.5 Moving away from activity–based funding
      • Case study 17 — HealthLinks
    • 6.6 Taking calculated risks to advance funding reform
  • Appendix A Conduct of the study
  • References

Printed copies

Printed copies of this report can be purchased from Canprint Communications.

Publications feedback

We value your comments about this publication and encourage you to provide feedback.

Submit publications feedback