Chronic Disease Management Clinic

The Chronic Disease Management (CDM) Clinic supports the management of clients with complex medical needs.


Clients attending the CDM Clinic are assessed by a multidisciplinary team, including a registered nurse, a clinical physician and a clinical pharmacist, to determine areas of their health that require further investigation or a streamline of service provision.

Registered Nurse provides a physical assessment, falls risk assessment, assessment of psychosocial issues that may impact on health outcomes, Mini Mental State Examination as required, education of disease process and information of services available to provide management strategies.

Clinical Pharmacist provides an intensive assessment of medications taken by the client to determine the requirement of the medication, correct administration of the medication and drug interactions. Comprehensive medication education is also provided to clients and carers. If required, Pharmacy Outreach Service can be arranged to assess all aspects of the client’s medication management in their home environment.

Clinical Physician provides a holistic approach to the client’s medical and psychosocial issues. Assessment, further investigations and planning of disease management are undertaken with the aim of improving health outcomes.

A multidisciplinary care plan is provided to other care providers to assist in streamlining the needs of the client.


Community Health Care services are charged in accordance with the Victorian Department of Health Fee policy.

$8.30 for Health Care Card Holders and low income
$12.70 medium income
$83.70 high income
No charge for Aboriginal & Torres Strait Islander background; temporary protection visa/asylum seeker/refugee coming to Australia in the last five years; no income.

Eligibility criteria

Clients who live/work/study or consult a GP in the City of Greater Dandenong, City of Casey or Shire of Cardinia.

Referral details

A Service Coordination Template Tool (SCTT) and a GP referral letter are required for new referrals to the CDM clinic.

The SCTT should be faxed / emailed to the CDM Clinic Coordinator at the time of initial referral. The GP letter should be presented to the CDM Coordinator at the initial clinic appointment.

A letter will be sent to the client with details regarding the CDM Clinic appointment, including a list of items required at the appointment.

Southern Health medical records are accessed to assist in the comprehensive assessment of each client. Other medical records and information regarding any further assessments and investigations will assist in providing optimum care to the client.


Clinic is held on Thursday morning.

Staff available on Tuesday and Thursday from 07.30am-4pm


Casey Hospital, Kangan Drive, Berwick. (Next to the Emergency Department in the Monash Heart area).

Contact information

Help contacting us

For people who need help with English or an interpreter: : TIS: 131 450

For people with hearing or speech loss: TTY: 1800 555 677

Speak and Listen: 1800 555 727

Internet relay: National Relay Service: