Osteoarthritis Chronic Care Program (OACCP) Model of Care


The OACCP aims to provide interventions that support people with osteoarthritis of the hip and/or knee to:

  • Self-manage their condition and co-morbidities; 
  • Reduce pain, increase function, and improve their quality of life; 
  • The OACCP considers and supports management of physical and psychosocial health care needs.


The OACCP model of care has been implemented and evaluated in eight LHDs in NSW. Most of the participants have been on the NSW public hospital wait list for elective hip or knee joint replacement surgery.

There have been a number of clinical gains, including:

  • 11% of participants with knee arthritis who have been waiting for knee joint replacement surgery have agreed they do not need surgery at this time
  • About 4% of those with hip arthritis have been supported to access earlier hip joint replacement surgery through their participation in the OACCP
  • Reductions or improved management of co-morbidities e.g. improved control of hypertension, reductions in weight.

A telephone survey of some of the participants who have elected to remove themselves from the surgical wait list has revealed that > 95% remained off the wait list and have not proceeded to surgery in the public or private sector 12–24 months after leaving OACCP.


The OACCP model of care is a multidisciplinary team intervention coordinated by a senior physiotherapist for people who have significant osteoarthritis of the knee and/or hip.

The program uses behaviour change theory over a period of 12 months to help support management of their overall health such as maintaining medication regimens, dietary change and appropriate exercise programs. The program focuses on joint health and mobility, and provides encouragement and support to access interventions within the community/wider health system. 


The OACCP was implemented in NSW to support people who are on the wait list for elective hip and/or knee joint replacement surgery to be actively working towards better health outcomes prior to their surgery. 

Besides the core aims of the OACCP, it was determined many people require early assessment and interventions to support management of:

  • Their co-morbidities (of which many have > 4 that require chronic care interventions)
  • Prevention of falls
  • Reducing avoidable late cancellations of surgery
  • Be more realistic concerning their expectations for outcomes during and after their surgery
  • Reducing length of stay in hospital
  • Reducing the need for sub-acute rehabilitation.

A chronic-care model of care was chosen as this includes all the needs of this patient cohort, including access to the multidisciplinary team, self-management support, interventions for physical, social, emotional and psychological needs, underpinned with the tenets of health coaching. This means ‘patients as partners’ in their health care is truly applied.


  • CECFalls Prevention Program
  • Arthritis NSW
  • Murrumbidgee Medicare Local
  • North Coast NSW Medicare Local
  • Northern Sydney Medicare Local
  • Sydney North Shore and Beaches Medicare Local

Key Dates

Pilot Sites

Implementation Sites

Hunter New England Local Health DistrictHunter New England Local Health District


Mid North Coast Local Health DistrictMid North Coast Local Health District

Port Macquarie, Coffs Harbour, North Coast NSW Medicare Local

Murrumbidgee Local Health DistrictMurrumbidgee Local Health District

Murrumbidgee Medicare Local, Wagga and surrounding towns

Nepean Blue Mountains Local Health DistrictNepean Blue Mountains Local Health District

Penrith, Katoomba

Northern Sydney Local Health DistrictNorthern Sydney Local Health District

Royal North Shore Hospital, Northern Sydney Medicare Local, Sydney North Shore & Beaches Medicare Local

South Eastern Sydney Local Health DistrictSouth Eastern Sydney Local Health District


South Western Sydney Local Health DistrictSouth Western Sydney Local Health District

Fairfield, Campbelltown, Bowral


The OACCP has been evaluated through:

  • A purpose-built data system that all OACCP teams use to guide and record their clinical assessments over time. This system is inclusive of validated questionnaires that auto-sum each completed form, auto-generated letters for GPs (and others as required), and it produces lists of those participants due for re-assessment.
  • An economic evaluation by the ACI Health Economics and Analysis Team working with the Musculoskeletal Network on hospital admission and projections over the next decade is being undertaken. Characteristics of successful OACCP teams and further understanding of the outcomes of people who elect to remove themselves from the elective hip and/or knee joint replacement surgical waitlist due to improvements in their health status after participating in the OACCP are also key evaluation measures that will be benchmarked.

Related Initiatives

Further Details

The model of care document and site manual can be found at this link:



Robyn Speerin
ACI Musculoskeletal Network Manager
02 9464 4633

Chris Shipway
Director, Primary Care and Chronic Services
02 9464 4603

Page Top | Added: 7 November 2013 | Last modified: 9 February 2015

Robyn Speerin
ACI Musculoskeletal Network Manager
02 9464 4633