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Chronic Disease Model of Care

A Model of Care is a set of interventions, activities, and tasks that is carried out consistently and targeted to patients with particular conditions.  It includes the range of care team members provide, their roles and responsibilities, the frequency of care delivery, and the protocols that they follow. The care model is designed, in total, to interact with people to improve their circumstances in predictable ways​

Rural and remote communities have higher rates of chronic disease, avoidable hospitalisation and preventable mortality compared to major cities and regional centres.  The sole role of GPs is to improve community health outcomes and wellness, and intervene early to manage chronic disease, to reduce the number of people in the community that develop chronic conditions requiring hospital admission and impact quality of life.  The RARMS Chronic Disease Cycle of Care provides a broad framework through which RARMS works with our patients to provide a multidisciplinary team based approach to improving health and managing chronic diseases to reduce unnecessary hospitalisations.


Models of Care RARMS

In developing our Models of Care RARMS analyses the needs of our local communities and patient cohorts to ensure we are:

  • Matching our Models of Care (team and services) to the needs of the local patients and the community context

  • Achieving the best health outcomes for our patients and communities

  • Ensuring that our care teams are confident in the clinical approach

  • Achieving RARMS Vision for Healthy Rural and Remote Communities

  • Ensuring our Model of Care is sustainable over time.

RARMS applies a patient and community-centred approach to the design of our Models of Care that aligns with the needs and expectations of our communities. The process includes defining the goals, available resources and needs from the patients’ perspective, understanding the community context in which care is  delivered, developing a shared concept for how a Model of Care might be delivered, pilot testing the model, and refining the enhanced care model. 


RARMS has developed systematic, robust quality improvement methods overseen by RARMS Clinical Governance Committee and an iterative learning process to evaluate and redesign interventions, workforce, workflows including tracking patient outcomes. 

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