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Self Management of Chronic Conditions (SMoCC) service

Refer a patient ❯

This service delivers The COACH Program® which is a statewide, structured, telephone-based, chronic disease program that helps people with in-scope chronic conditions such as:

  • coronary artery disease (CAD), (such as myocardial infarction, angina pectoris, cardiac stenting or cardiac bypass surgery)
  • type 2 diabetes
  • pre-diabetes
  • chronic obstructive pulmonary disease (COPD).

The service:

  • aims to improve the quality of life of participants by developing in them the self-management skills required to reduce the progression of their chronic condition, and to better navigate the health system
  • employs a partnership approach between the patient and their General Practitioner (GP). Patients are taught the skills required to self-manage their condition, with their GP as their primary care provider
  • utilises The COACH Program, which has been shown to reduce avoidable hospitalisations and provides another option for individuals who have limited access or willingness to attend conventional services.

The program runs for approximately 6 months, with a call every 4-6 weeks.

Benefits for patients

The program is delivered over the telephone by a Registered Nurse at an agreed time. The service operates Monday to Friday from 08.00am to 08.30pm and Saturday from 08.00am to 4.30pm.

The program:

  • Is shown to reduce the risk of future hospital admissions.
  • Is free for participants residing in Queensland.
  • Enables patients to better manage their health and symptoms of chronic disease.
  • Has been shown to reduce anxiety, improve perception of general health, mood and fitness.

Coaches are qualified health professionals who discuss treatment specific to a patient's condition. This can include health targets, treatments, and ways to manage risk factors, such as:

  • blood glucose levels
  • cholesterol
  • blood pressure
  • diet and nutrition
  • smoking
  • physical activity
  • weight.

Criteria

Individuals must be over the age of 18, be self-caring and a resident of Queensland and have been diagnosed with one or more of the following conditions:

  • coronary artery disease (CAD), (such as myocardial infarction, angina pectoris, cardiac stenting or heart bypass surgery)
  • type 2 diabetes
  • pre-diabetes
  • chronic obstructive pulmonary disease (COPD).

Resources

Contact

If you have any further questions about the service, please email SMOCC@health.qld.gov.au.

Last updated: 14 April 2021