Primary Care Impact Grants - Supporting Chronic and Complex Disease Management
Chronic Disease Prevention Grants: Awardees
Healthy North Coast has awarded multiple rounds of the Chronic Disease Prevention Grants to support better care for chronic diseases, which are long-term conditions with lasting effects on individuals and communities. These diseases are a leading cause of disability and death in Australia, but nearly 40% of their burden could be prevented by addressing modifiable risk factors and improving disease management.
View current Primary Care Impact Grant opportunities available and applications.
Healthy North Coast’s approach prioritises flexible, locally tailored grants that leverage existing relationships and infrastructure to rapidly address the most pressing community needs. By fostering local partnerships, valuing community expertise, and maintaining a strong equity focus including dedicated support for ACCHOs, it delivers more relevant, culturally appropriate care and improves access and outcomes for underserved populations.
The first round of Chronic Disease Prevention grants was evaluated in February 2025. There were 18 applications received, of which 11 were awarded. The second round of Chronic Disease Prevention grants was evaluated in April 2025. There were 22 applications received, of which nine were awarded.
Below is a list of the successful applicants and a summary of their proposal and the panel’s evaluation.
Evaluation Guide
Each grant application is evaluated separately by all panel members utilising a rubric, the panel is then convened to reach a consensus decision.
Each evaluation criteria is scored on a scale of 0-10. The awardee list below includes the panel’s average score on each of these criteria out of ten, with the panel’s overall comments.
There is no specific “pass mark” to be awarded a grant. Each proposed program is different and has a varied approach at meeting the needs of their community. In testament to the high-quality applications received, successful applications awarded the full funding amount averaged approximately 7/10 or above across the four criteria.
The evaluation rubric has four key areas:
There is no specific “pass mark”, as each program is different and has a varied approach at meeting the needs of their community.
Ballina Health Centre, Ballina
Ballina Health Centre delivers a comprehensive cardiovascular disease prevention and management model for adults aged 45–75 in Ballina. Aligned with national guidelines, it provides cardiovascular risk assessments, lifestyle counselling, allied health referrals, and education to support behaviour change. Patients at moderate or high risk will receive structured interventions and monitoring at 3, 6, and 12 months. Outcomes will be measured through quality-of-life tools, clinical indicators, and patient feedback. By embedding a team-based approach involving nurses, GPs, and allied health professionals, the program aims to improve early detection, reduce long-term complications, and enhance patient self-management and overall well-being.
Prevention Strategy: Evidence-based and multidisciplinary cardiovascular management in primary care.
Chronic Disease Prevention Grant - Round 3 Awardee
Evaluation Summary
Using grant funds to build a model of care and team capacity that will benefit the community through and after the grant period.
Grant Awarded: $30,000
Coffs Coast GP Super Clinic, Coffs Harbour
Coffs Coast GP Super Clinic will deliver an integrated, multidisciplinary model of care for patients with Type 2 Diabetes in the Coffs Harbour region by embedding specialist and allied health expertise into general practice. The program will provide in-practice education, quarterly case conferencing, and culturally responsive, team-based care to support earlier intervention, stronger self-management, and enhanced clinical capability within primary care. Focus is on Aboriginal and Torres Strait Islander peoples, culturally and linguistically diverse groups, disadvantaged populations, and frail older adults, aiming to reduce complications, prevent hospitalisations, and improve long-term outcomes through a sustainable, primary care–based approach.
Prevention Strategy: Utilising specialist case conferences to maximise the effectiveness of treatment for patients with diabetes.
Chronic Disease Prevention Grant - Round 3 Awardee
Evaluation Summary
A program that proposes improving patient outcomes with existing specialist and allied health resources, while also building capacity in the general practice to manage these challenging patients.
Grant Awarded: $49,850
First Light Active, Ballina
First Light Active will deliver a preventative and early intervention wellbeing model that uses a multi-disciplinary, team-based approach involving GPs, exercise physiologists, dietitians, and physiotherapists, integrating diagnostics and VALD technology to track progress. Individualised and group-based care, combined with case conferencing, will empower patients to better understand and manage their health, leading to improved outcomes and reduced hospitalisations.
Prevention Strategy: Technology-supported active lifestyle interventions for chronic disease patients supported by a strong multidisciplinary team care model.
Chronic Disease Prevention Grant - Round 3 Awardee
Evaluation Summary
A multidisciplinary model of care based on gathering patient data to guide treatment but also share that data with the patient throughout the journey to increase motivation and adherence.
Grant Awarded: $35,000
Fletcher Street Cottage, Byron Bay
A trauma-informed, nurse-led drop-in clinic embedded in Fletcher Street Cottage to increase healthcare access for women experiencing or at risk of homelessness. The program aims to prevent chronic disease, improve health outcomes, reduce hospitalisations, and build trust through a safe women-only environment.
Prevention Strategy: This program aims to provide screening and preventative healthcare to a population group that is often unable to access health care and has poor health outcomes.
Chronic Disease Prevention Grant - Round 3 Awardee
Evaluation Summary
An established service provider that is motivated to improve the health of their community with much needed care.
Grant Awarded: $50,000
Help Prevent Falls, Coffs Harbour
The Help Prevent Falls program aims to reduce the risk of falls among people aged 65+ in the Coffs Harbour region by addressing physical, educational, nutritional, and social factors. The program will run six times per year in small groups, supported by geriatricians, GPs, aged care teams, Aboriginal health services, and NDIS networks. It focuses on preventing hospital admissions, reducing length of stay, and easing demand on acute care through targeted, evidence-based interventions.
Prevention Strategy: Proactive, evidence-based falls prevention.
Chronic Disease Prevention Grant - Round 3 Awardee
Evaluation Summary
A local solution to a region-wide challenge, with existing relationships to existing acute and primary care providers.
Grant Awarded: $43,148
Lifestyle Medicine Learning, Tweed Heads
The Sarcopenia Early Detection (SarC-ED) program seeks to identify, engage, and support adults aged 60–80 at risk of sarcopenia through early screening, targeted interventions, and ongoing evaluation. Eligible participants will complete a three-month program with outcomes assessed at baseline, six weeks, and completion. Ongoing follow-ups at 3, 6, and 9 months will track the sustainability of outcomes using patient-reported measures. By integrating protocols into pharmacy and clinical practice, the program aims to reduce falls, frailty, and hospitalisations while improving independence and quality of life, creating a scalable model for healthy ageing.
Prevention Strategy: A structured program of tailored physical activity, nutrition support, and self-management education.
Chronic Disease Prevention Grant - Round 3 Awardee
Evaluation Summary
An evidence-based model of care with a robust evaluation strategy that will help guide the future of sarcopenia management in primary care.
Grant Awarded: $40,000
Lisa Strauss Health, Ocean Shores
Lisa Strauss Health delivers group-based, dietitian-led education sessions with a focus on the prevention and management of coronary heart disease and type 2 diabetes. Each two-hour workshop provides evidence-based information on nutrition and lifestyle, practical healthy eating guidance, and goal-setting activities. Take-home resources are provided to support long-term behaviour change. Delivered in accessible community settings, sessions are interactive, culturally sensitive, and adapted for older adults’ literacy and learning needs. Alongside improving health literacy and self-management, the workshops foster peer connection and reduce social isolation, contributing to healthier ageing and reduced chronic disease burden.
Prevention Strategy: Education and community-building to support healthy lifestyle choices.
Chronic Disease Prevention Grant - Round 3 Awardee
Evaluation Summary
A motivated allied health provider motivated to meet the needs of her community with a well-planned program.
Grant Awarded: $24,300
Medical on William, Port Macquarie
Medical on William aims to increase the number of patients receiving comprehensive cardiovascular risk assessments by 25% within 12 months and improve long-term heart health outcomes for at-risk individuals. The initiative will address risk factors including smoking, obesity, hypertension, dyslipidaemia, diabetes, severe mental illness, social isolation, and family history of heart disease. By embedding risk assessments into routine practice and linking patients with follow-up plans, the program seeks to prevent complications, reduce hospitalisations, and empower patients to manage their cardiovascular health.
Prevention Strategy: A structured, proactive, nurse-led care model to increase screening and preventative activities.
Chronic Disease Prevention Grant - Round 3 Awardee
Evaluation Summary
An established model of care looking to expand its reach to underserved patients.
Grant Awarded: $25,000
Mullumbimby Comprehensive Health Centre, Mullumbimby
Mullumbimby Comprehensive Health Centre supports the development of a Multidisciplinary Case Conferencing (MDCC) service utilising staff from the Mullumbimby Comprehensive Health Centre. The service aims to provide multidisciplinary support to general practitioners and patients that otherwise do not have access to these services. The service will initially support local providers then expand to offer services across the HNC region.
Prevention Strategy: Facilitating best practice multidisciplinary care to practices and patients where these services are not available locally.
Chronic Disease Prevention Grant - Round 3 Awardee
Evaluation Summary
A strong clinical model with good potential for expansion that addresses many challenges for patients living in rural and remote areas.
Grant Awarded: $50,000
Northern NSW Local Health District Health Promotion Unit
Northern NSW Local Health District Health Promotion Unit aims to address the high prevalence of smoking and vaping among Aboriginal and Torres Strait Islander communities by providing Nicotine Replacement Therapy, training, Smokerlyzer use, and brief interventions delivered by local Aboriginal Medical Service (AMS) staff. NNSWLHD Health Promotion unit will support the AMS partners with implementing and evaluating the community impact.
Prevention Strategy: Subsidised access to smoking cessation activities delivered in collaboration with local Aboriginal Medical Services.
Chronic Disease Prevention Grant - Round 3 Awardee
Evaluation Summary
The model proposes collaboration that uses the strengths of each provider involved to get the best outcome for their communities.
Grant Awarded: $32,000
Pain Revolution
Pain Revolution will support primary care to deliver contemporary pain education and treatment by training health professionals to be Local Pain Educators. This model embeds ongoing capacity building, strengthens referral pathways and improves chronic pain management. The program will also support the 2026 Pain Revolution Rural Outreach Tour, bringing world-class pain educators such as Dr Lorimer Moseley to communities and health care providers across our region.
Prevention Strategy: Capacity building and education to improve the management of highly prevalent and challenging medical condition.
Chronic Disease Prevention Grant - Round 3 Awardee
Evaluation Summary
An opportunity to bring world-leading pain researchers and educators to support our region.
Grant Awarded: $50,000
Parkinson’s NSW, Coffs Harbour
Parkinson’s NSW will improve the quality of life for people living with Parkinson’s disease (PD) in four Residential Aged Care Facilities (RACFs) on the Mid North Coast. Over 12 months, each RACF will establish a Parkinson’s Support Group for residents and carers, review and adapt wellness programs to include PD specific activities and provide specific training for at least 50% of staff in direct resident care. This initiative responds to identified gaps in aged care by embedding disease-specific supports, enhancing staff skills, and building sustainable care models tailored to older adults with Parkinson’s.
Prevention Strategy: A model that combines active prevention and management of complications, building a patient community and training clinicians and staff.
Chronic Disease Prevention Grant - Round 3 Awardee
Evaluation Summary
A model of care based on a strong understanding of community need, delivered by skilled specialists with capacity to expand
Grant Awarded: $50,000
Tweed Banora Medical Centre, Tweed Heads
Tweed Banora Medical Centre aims to expand nursing capacity to improve early detection, prevention, and management of chronic conditions. By increasing chronic disease management nurse hours, the centre can provide comprehensive health assessments, follow-up care, and patient education to an additional 453 patients. Priority groups include Aboriginal and Torres Strait Islander people, patients aged 45–49 and over 75 eligible for health checks, and those living with chronic conditions such as diabetes and cardiovascular disease. Through proactive recalls, systematic screening, and multidisciplinary referrals, the program aims to reduce complications, prevent hospital admissions, and improve long-term health outcomes.
Prevention Strategy: Nurse-led proactive chronic disease management in general practice.
Chronic Disease Prevention Grant - Round 3 Awardee
Evaluation Summary
A clear understanding of their community need with the aim to reach priority populations with preventative care.
Grant Awarded: $20,000
Banora Point Medical Centre, Tweed Heads
The Banora Point Medical Centre program establishes nurse-led diabetes clinics to enhance chronic disease management, provide early intervention, and promote preventive care for individuals with or at risk of diabetes. The clinics will conduct annual screenings, care planning, health education, and coordinate with GPs and allied health to manage and monitor patient health outcomes.
Prevention Strategy: Nurse-led care to increase disease screening and prevention.
Chronic Disease Prevention Grant - Round 2 Awardee
Evaluation Summary
A thorough application with a clear aim to meet the needs of their community.
Grant Awarded: $24,674
Keen Street Clinic, Lismore
Keen Street Clinic will expand its chronic disease management services by embedding structured mental, emotional, and social health assessments into care planning. The initiative aims to improve care plan uptake, address disengagement, and enhance outcomes for patients with chronic physical conditions, particularly those affected by trauma, isolation, or natural disasters.
Prevention Strategy: Addressing complicated mental health co-morbidities in chronic disease patients that can impair their ability to recover.
Chronic Disease Prevention Grant - Round 2 Awardee
Evaluation Summary
A comprehensive plan to further understand their community’s needs, upskill their staff, create patient resources and build their long-term capacity to prevent chronic disease.
Grant Awarded: $50,000
Movement Logic Physiotherapy, Coffs Harbour
This program delivers person-centred, evidence-based care for people with knee and hip osteoarthritis (OA) in the Coffs Harbour region. Led by advanced musculoskeletal physiotherapists, the model includes comprehensive assessments, small group exercise and education sessions, and community-based health promotion to support early intervention, behaviour change, and reduce reliance on surgical interventions.
Prevention Strategy: Supported engagement with allied health to provide proactive lifestyle interventions and education.
Chronic Disease Prevention Grant - Round 2 Awardee
Evaluation Summary
Experienced allied health professionals working to reduce the health system demand of joint replacement surgery and improve patients’ quality of life.
Grant Awarded: $50,000
Ocean Shores Medical Centre, Ocean Shores
This RN-led clinic at Ocean Shores Medical Centre delivers proactive chronic disease prevention and management through early identification, risk assessments, and care planning. Focused on high-risk and underserved groups, it aims to reduce hospitalisations, improve long-term outcomes, and embed sustainable nurse-led chronic care into everyday practice.
Prevention Strategy: Early intervention through proactive nurse-led screening.
Chronic Disease Prevention Grant - Round 2 Awardee
Evaluation Summary
A strong understanding of their community needs based on their practice data, with a plan to effectively use nurses’ skills to address those needs, supported by a strong evaluation framework.
Grant Awarded: $25,000
O-Plus Health Iluka, Iluka
O Plus Health will establish a multidisciplinary High Risk Foot Clinic in the Clarence Valley region to address a critical service gap for people with type 2 diabetes at risk of foot complications. The program aligns with national standards for high-risk foot services and involves endocrinologists, podiatrists, diabetes educators, and physiotherapists. It aims to prevent ulcerations, hospitalisations, and amputations by delivering coordinated, evidence-based care locally.
Prevention Strategy: Proactive multidisciplinary team care that prevents significant negative outcomes for diabetes patients.
Chronic Disease Prevention Grant - Round 2 Awardee
Evaluation Summary
A greatly needed local service where there are no other accessible alternatives.
Grant Awarded: $50,000
Port Macquarie Wound Care Clinic
This nurse-led program delivers specialist wound care and chronic disease management to vulnerable patients across the Hastings-Macleay region. Targeting individuals unable to access mainstream funding or care, it provides timely, evidence-based intervention to prevent hospitalisations, reduce amputations, and improve patient self-management. Services are delivered in-clinic and through community-based outreach, ensuring equitable access for underserved populations.
Prevention Strategy: Preventing secondary complications and preventable hospitalisations by supporting patients with limited access to wound care.
Chronic Disease Prevention Grant - Round 2 Awardee
Evaluation Summary
A program that focuses entirely on health inequalities by overcoming the financial barriers to access where prevention effort has significant outcomes for patients.
Grant Awarded: $50,000
Tweed Health For Everyone, Tweed Heads
Tweed Health for Everyone will expand its existing multidisciplinary wound care service to better meet the needs of high-risk patients in the Tweed region. The program focuses on reducing preventable hospital admissions and improving chronic wound management outcomes by delivering weekend care to vulnerable populations, including those with diabetes, vascular disease, post-surgical complications, and residents in aged care facilities.
Prevention Strategy: Accessible nursing care that reduces preventable complications that occur outside regular business hours.
Chronic Disease Prevention Grant - Round 2 Awardee
Evaluation Summary
An established service looking to expand to further meet the needs of their community.
Grant Awarded: $40,000
Wauchope Physiotherapy and Sports Rehab Centre, Wauchope
This program delivers a structured, evidence-based falls prevention initiative targeting older adults in the Wauchope region. Through supervised group classes led by physiotherapists, the program addresses strength, balance, and mobility to reduce fall risk, support independence, and prevent avoidable hospitalisations. It replaces a recently discontinued public program, filling a critical service gap for a vulnerable population.
Prevention Strategy: Falls prevention through evidence-based physiotherapy intervention.
Chronic Disease Prevention Grant - Round 2 Awardee
Evaluation Summary
A comprehensive falls prevention program delivered in an underserved region.
Grant Awarded: $49,320
Your Family Practice, Lakewood
Your Family Practice will establish a weekly Well Women’s Clinic in Camden Haven to empower women through access to general practice services, IUD insertions, education, and trauma-informed care. The clinic addresses a critical gap in the region, improving women’s ability to make informed decisions about their health and life circumstances, particularly in relation to domestic violence, reproductive care, and preventative health.
Prevention Strategy: Offering proactive and preventative services in a safe environment that meets the needs of at-risk patients.
Chronic Disease Prevention Grant - Round 2 Awardee
Evaluation Summary
A thoughtful approach to meeting an unmet need in a small community. Addressing both priority populations and access barriers.
Grant Awarded: $50,000
Bowra GP Clinic, Bowraville
Bowra GP Clinic, in partnership with the Mid North Coast Local Health District, will deliver a culturally tailored group program focused on improving health literacy and preventing chronic disease through nutrition, exercise, and blood pressure management. This community-requested initiative addresses the high burden of obesity, hypertension, and diabetes in the Aboriginal population of Bowraville.
Prevention Strategy: Small group interventions focusing on exercise and lifestyle interventions, with increased medical monitoring and support for participants.
Chronic Disease Prevention Grant - Round 1 Awardee
Evaluation Summary
A community driven program to provide primary and secondary prevention support to high disease risk patients.
Grant Awarded: $49,000
CHC Medical Centre, Coffs Harbour
CHC Medical Centre will implement a proactive, data-informed chronic disease screening program to detect and manage diabetes and cardiovascular risk early in at-risk populations across the Mid North Coast, particularly among Aboriginal and Torres Strait Islander patients. The program integrates enhanced screening, education, medication reviews, and culturally responsive care coordination.
Prevention Strategy: Targeting undiagnosed but high-risk patients and engaging them with GPs, practice nurses, diabetes educators and pharmacists.
Chronic Disease Prevention Grant - Round 1 Awardee
Evaluation Summary
A clear goal to increase screening rates amongst priority populations utilising multidisciplinary team care.
Grant Awarded: $50,000
Kennedy Drive Medical Centre, Tweed Heads
Kennedy Drive Medical Centre will deliver a prevention-focused chronic disease program that centres on mental health as a contributing factor to long-term illness. The program targets at-risk groups, primarily Indigenous Australians and patients from lower socioeconomic backgrounds and uses a nurse-led, culturally safe approach to enhance early identification, education, and patient engagement.
Prevention Strategy: Proactive engagement with chronic disease patients to prevent secondary mental health conditions.
Chronic Disease Prevention Grant - Round 1 Awardee
Evaluation Summary
A bulk-billing practice looking to address an unmet need in underserved and financially disadvantaged patient populations.
Grant Awarded: $29,500
McKay Street Surgery, Macksville
McKay Street Surgery’s program focuses on early detection, education, lifestyle change, and coordinated care to prevent chronic diseases. Through screenings, monitoring, and support, it aims to reduce risks, improve outcomes, and lower hospital admissions.
Prevention Strategy: Formalising a multidisciplinary approach to the prevention and early intervention of chronic diseases in the ageing population.
Chronic Disease Prevention Grant - Round 1 Awardee
Evaluation Summary
A long term plan that includes local collaboration, upgrading medical equipment and providing staff education that can raise the capacity of the practice to meet their community’s needs.
Grant Awarded: $30,000
OneBridge, Ballina
OneBridge, in partnership with Mary’s Place, will deliver a place-based, nurse-led chronic disease prevention and management program targeting individuals experiencing homelessness, poverty, and chronic illness in Ballina. The service will operate weekly for 12 months, integrating primary care, telehealth access, allied health pathways, and preventative care.
Prevention Strategy: Engagement with an underserved population to encourage proactive health care.
Chronic Disease Prevention Grant - Round 1 Awardee
Evaluation Summary
A strong proposal to deliver nurse-led care with a clear understanding of community need and existing access barriers.
Grant Awarded: $50,000
Prema House, Lismore
Prema House will expand its nurse-led clinic model to proactively address chronic disease and cancer risk across the Richmond Valley. Through a culturally inclusive, bulk-billed service model, this program targets screening gaps, health inequity, and chronic condition burden among priority populations.
Prevention Strategy: Targeted screening for cancer and chronic conditions supported by tailored health education and patient empowerment through efficient use of nursing workforce.
Chronic Disease Prevention Grant - Round 1 Awardee
Evaluation Summary
Clear proposed targets for screening rates and patient outcomes and a dedicated plan to focus on reaching priority populations.
Grant Awarded: $30,000
Rekindling The Spirit, Lismore
Rekindling the Spirit will deliver an extended 48-week Aboriginal Healthy Lifestyle Program, building on the success of the NSW Knockout Health Challenge model. The program aims to empower Aboriginal clients and families across Lismore to make sustainable health changes by integrating traditional knowledge, chronic disease education, and physical activity.
Prevention Strategy: Health education, exercise classes, traditional games and bush tucker education.
Chronic Disease Prevention Grant - Round 1 Awardee
Evaluation Summary
A strong community engagement focus on chronic disease prevention, fostering local community champions.
Grant Awarded: $50,000
Rose Avenue Medical Practice, Coffs Harbour
Rose Avenue Medical Practice will implement a structured, community-focused education program to raise awareness of hypertension and promote early detection. Through monthly 90-minute sessions, the program will engage local residents in blood pressure screening, multidisciplinary health education, and lifestyle intervention advice in a culturally inclusive and non-clinical setting.
Prevention Strategy: Primary and secondary prevention through community engagement and education in the ageing population.
Chronic Disease Prevention Grant - Round 1 Awardee
Evaluation Summary
Flexible delivery model in community and residential aged care sessions, engaging with multidisciplinary providers to maximise impact.
Grant Awarded: $50,000
Scotts Head Medical Practice, Scotts Head
Scotts Head Medical Practice will implement a locally delivered intravenous iron infusion service for patients at risk of or diagnosed with iron deficiency anaemia, particularly those who currently face long delays and significant travel barriers to access hospital-based treatment. The goal is to improve timely, local access to infusions for vulnerable patients across Scotts Head and surrounding rural communities.
Prevention Strategy: Establishment of a new service and workforce capacity building that overcomes access barriers and prevents secondary complications.
Chronic Disease Prevention Grant - Round 1 Awardee
Evaluation Summary
A well understood local need, with a clear plan to meet that need and a sustainability plan that continues beyond the grant period.
Grant Awarded: $15,000
The Physio Movement, Woolgoolga
The Physio Movement will deliver a structured, multidisciplinary pain management program in Woolgoolga and Yamba to address chronic musculoskeletal pain, a leading contributor to reduced mobility and chronic disease burden. The Persistent Pain Program integrates evidence-based pain education, functional rehabilitation, and lifestyle change support.
Prevention Strategy: Group based multidisciplinary pain service including exercise therapy and lifestyle interventions, with community outreach through education sessions and social media.
Chronic Disease Prevention Grant - Round 1 Awardee
Evaluation Summary
An evidence-based multidisciplinary approach to the management of chronic pain, a key risk factor in the development of chronic physical and mental health conditions.
Grant Awarded: $50,000
Woopi Medical Centre, Woolgoolga
Woopi Medical Centre will implement a practice-wide chronic disease prevention and management program focused on reducing disease progression, improving care coordination, and enhancing quality of life for high-risk patients. The initiative targets diabetes, cardiovascular disease, respiratory illness, musculoskeletal conditions, and kidney disease through proactive care planning, education, and culturally sensitive engagement.
Prevention Strategy: Health assessments that lead into group education and lifestyle interventions, supported referrals into allied health and production of patient education materials.
Chronic Disease Prevention Grant - Round 1 Awardee
Evaluation Summary
A plan that engages with their diverse patient population, with a focus on workforce training and development that will have long-term benefits for the patients of the practice.
