Chronic disease and prevention
Supporting healthier communities
Many chronic health conditions can be prevented, delayed or better managed with the right care and support.
Healthy North Coast works with communities, general practices, Aboriginal Medical Services, health professionals and local organisations to help people stay healthy, identify health concerns earlier and improve care for people living with chronic conditions.
Our work is guided by the health needs of North Coast communities, with a focus on prevention, early intervention, equitable access to care and supporting people to live healthier lives.
Looking after your health
Looking after your health
There are different ways you can take care of your health and reduce the impact of chronic disease.
Prevent disease
Healthy eating, physical activity, not smoking or vaping, reducing alcohol consumption, looking after your mental health and staying socially connected can all contribute to better long-term health.
Find it early
Regular health checks, screening and immunisation can help identify health risks and conditions earlier.
Manage a condition
If you’re living with a chronic condition, your GP and other health professionals can help you understand your condition and coordinate the care and support you need.
Find support
Health and community services are available across the North Coast, including culturally safe services for Aboriginal and Torres Strait Islander people.
Understanding chronic disease
Chronic conditions are long-term health conditions that can affect a person’s health and quality of life over many years.
They include:
- cardiovascular and heart disease
- diabetes
- cancer
- chronic respiratory conditions, including asthma and chronic obstructive pulmonary disease (COPD)
- chronic kidney disease
- musculoskeletal conditions, including osteoarthritis
- osteoporosis
- chronic pain
- neurological conditions
- long-term mental health conditions.
Some people live with two or more chronic conditions at the same time. This can make managing health more complex and may involve care from several health professionals.
While not all chronic conditions can be prevented, there are things we can do to reduce our risk, identify health concerns earlier and better manage existing conditions.
Chronic disease on the North Coast
Chronic disease is a significant health priority for our region.
Healthy North Coast’s Health Needs Assessment shows that chronic conditions affect communities across the North Coast differently.
In 2023, the most common chronic conditions recorded among general practice patients in our region included anxiety, osteoarthritis, asthma, depression and osteoporosis. Around 17% of general practice patients were living with multiple chronic conditions.
People living in some communities experience a greater burden of chronic disease, while factors such as distance, cost and access to appropriate health services can make managing health more difficult.
Understanding these differences helps Healthy North Coast work with communities and health providers to focus investment and services where they are most needed.
Prevention in our communities
Healthy communities are built locally.
That’s why Healthy North Coast invests in local organisations and health providers that understand their communities and can develop practical approaches to preventing chronic disease.
Through our Chronic Disease Prevention Grants, organisations across the North Coast are delivering projects that make preventive health care more accessible and respond to the different needs of their communities.
These projects support areas including physical activity, healthy eating, health screening, chronic disease education, women’s health, healthy ageing, Aboriginal health, chronic pain and improving access to care for people experiencing disadvantage.
Chronic Disease Prevention grants in action
Supporting healthy lifestyles in Aboriginal communities
Rekindling the Spirit – Lismore
Rekindling the Spirit is delivering an extended Aboriginal Healthy Lifestyle Program supporting Aboriginal people and families to make sustainable changes to their health.
The program combines chronic disease education, physical activity, traditional games and bush tucker education, bringing together health promotion and cultural knowledge in a community-led setting.
Improving access to health care for people experiencing homelessness
OneBridge – Ballina
Working in partnership with Mary’s Place, OneBridge is delivering a nurse-led chronic disease prevention and management program for people experiencing homelessness, poverty and chronic illness.
The program connects people with primary care, telehealth, allied health and preventive health services, helping people access care who may otherwise experience significant barriers.
Preventive health care for women
Fletcher Street Cottage – Byron Bay
A trauma-informed, nurse-led clinic is improving access to health care for women experiencing or at risk of homelessness.
The women-only service provides screening and preventive health care in a safe and accessible environment, with a focus on building trust, preventing chronic disease and improving longer-term health outcomes.
Supporting people with osteoarthritis
Movement Logic Physiotherapy – Coffs Harbour
This initiative supports people living with knee and hip osteoarthritis through assessment, small-group exercise, education and community health promotion.
The program focuses on early intervention and helping people better understand and manage their condition.
Improving chronic disease prevention in Aboriginal communities
Bowra GP Clinic – Bowraville
Bowra GP Clinic, working with Mid North Coast Local Health District, is delivering a culturally tailored program focused on nutrition, exercise, blood pressure management and health literacy.
The program supports people to better understand their health and reduce their risk of developing chronic conditions.
Preventing chronic disease through screening
Prema House – Lismore
Prema House is expanding its nurse-led clinic model to improve screening for chronic disease and cancer across the Richmond Valley.
The service focuses on people who may experience greater barriers to accessing health care, combining targeted screening with health education and support.
Aboriginal health and chronic disease
Aboriginal and Torres Strait Islander people experience a greater burden from many chronic conditions and can face additional barriers to accessing health care.
Healthy North Coast works in partnership with Aboriginal Medical Services and Aboriginal communities across our region to improve access to culturally safe care, strengthen prevention and support people living with chronic conditions.
Integrated Team Care
Integrated Team Care supports eligible Aboriginal and Torres Strait Islander people living with chronic health conditions to access coordinated and culturally appropriate care.
Healthy North Coast partners with Aboriginal Medical Services across the North Coast to deliver the program.
Depending on a person’s needs, support can include:
- coordinating care between different health professionals
- helping people access services included in their GP care plan
- connecting people with allied health professionals and specialists
- supporting people to manage their health
- helping people navigate the health system
- improving access to culturally appropriate health care.
Aboriginal Outreach Workers also play an important role in helping people connect with health services and supporting culturally appropriate care.
Aboriginal Community Controlled Health Organisations (ACCHOs)
ACCHOs provide culturally safe primary health care for Aboriginal and Torres Strait Islander people, families and communities.
Depending on the service, this can include preventive health checks, chronic disease management, immunisation, health education and connections with other health and community services.
Health checks and early detection
Finding a health concern early can make a significant difference.
Regular health checks with your GP or health professional can help identify risk factors before they develop into more serious health problems.
Depending on your age, health history and individual circumstances, this might include:
- blood pressure checks
- cardiovascular disease risk assessment
- diabetes risk assessment
- cholesterol checks
- kidney health checks
- Aboriginal and Torres Strait Islander health assessments
- cancer screening
- immunisation
- other age and risk-appropriate health assessments.
Talk to your GP, Aboriginal Medical Service or health professional about the health checks that are right for you.
Smoking and vaping
Smoking is a major preventable cause of chronic disease.
Vaping has also become an important health concern, particularly for children and young people.
Healthy North Coast monitors smoking and vaping trends across our region and works with health services and communities to support prevention and access to appropriate care.
Support is available if you would like to stop smoking or vaping.
Immunisation
Vaccination helps protect individuals and communities from preventable disease.
Keeping vaccinations up to date is important throughout life – from childhood immunisation through to vaccinations recommended during pregnancy, adulthood and older age.
Healthy North Coast works with general practices, Aboriginal Medical Services and other immunisation providers to strengthen vaccination services across our region.
Working together for better health
Preventing and managing chronic disease often involves more than one health professional or service.
Healthy North Coast works with general practices, Aboriginal Medical Services, hospitals, allied health providers, community organisations and other partners to create a more connected health system across the North Coast.
Our approach focuses on understanding local health needs, planning and investing in services, strengthening primary health care and improving how different parts of the health system work together.
For people living with chronic conditions, better connected care can mean earlier support, improved coordination between health professionals and a better experience navigating the health system.
Our goal is to support people to receive the right care, in the right place, at the right time.
Understanding health needs in our region
Healthy North Coast’s Health Needs Assessment helps us understand the health of people living across the North Coast and where opportunities exist to improve health outcomes.
Preventative health and chronic disease is one of the priority areas identified in the 2025–2028 Health Needs Assessment.
Our local evidence considers:
- chronic conditions and multimorbidity
- potentially preventable hospitalisations
- physical activity and nutrition
- smoking and vaping
- overweight and obesity
- alcohol and other drugs
- preventive health assessments
- cancer screening
- immunisation
differences in health outcomes and access between communities.
These insights help guide Healthy North Coast’s planning, partnerships, commissioning and investment.