A structured education and/or exercise service that begins when referred patients have an initial assessment to identify their goals and develop an action plan that empowers them to adopt self-management strategies to:

• make changes in their lifestyle
• adhere to prescribed medications
• return to, or to improve on, baseline everyday functioning
• develop coping strategies
• maximise psychological and social parameters
• develop a life-long approach to prevention



These can be facility-based, home-based, phone-based or web-enabled.