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In Reach Education
Chronic Disease Management
Specialist In-Reach Education in Chronic and Complex Disease Management
The In-reach education model brings together GPs and their staff with specialists and the patient to deliver in-practice education that benefits outcomes for health professionals and patients alike.
Through Healthy North Coast’s support, GPs are learning how to manage their more complex diabetics better, patients get consultations with a specialist and their GP together, and the knowledge that is imparted is shared cross the whole practice to deliver diabetic champions in areas of limited services.
Impact in the community
This program addresses critical healthcare challenges identified in the Healthy North Coast Health Needs Assessment 2022–2025, which highlights a significant undersupply and uneven distribution of medical specialists across the region. By integrating specialist knowledge directly into general practices, the program aims to enhance the management of chronic and complex conditions, improve access to specialist care, and strengthen collaboration between healthcare professionals.
Through a proven in-reach education model, specialists and allied health providers deliver tailored education sessions and shared care consultations within general practices. This approach equips GPs and their staff with the skills and confidence to manage complex cases, ensures patients receive high-quality care close to home, and fosters a collaborative healthcare environment.
Service implementation
Healthy North Coast has just completed a six-month pilot of a specialist in-reach education program with great success.
Dr Kate Gupta, an endocrinologist, and Michelle Bushell, a diabetes educator, have recently engaged with practices across the Port Macquarie region to share their diabetes expertise with local GPs, practice nurses and managers to support the care of patients in the area. Read more about the trial program.
Due to the success of the program from evaluation metrics, knowledge development and patient feedback we have taken the initiative to build the program and increase the capacity of specialists in the area to offer fighter training and support. Read more about the pilot program.
Join us in building a more connected, high-quality, and accessible health system for the North Coast community.Â
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If you have questions or want to learn more about the program please submit your details in the form below and our team will be in contact. Or if you are ready to apply, view application.
In Reach Specialist Education - Program Details
Chronic and complex disease management
The in-reach education is delivered by a local medical specialist attending a practice for the afternoon, along with supporting allied health staff or specialist nurse. A one-hour long education session is provided to all available practice staff, with catering arranged via Healthy North Coast to support attendance. One GP from the practice then completes five 45-minute case conferences with patients from the clinic.
The case conferences are 45 minutes in length as this provides the best value utilising MBS items for the practice, specialist and the attending allied health professionals, and allows the patient to be bulk-billed to remove cost barriers.
The specialist then returns to the practice after six months to follow up on the outcomes of the initial education session, and complete further case conferences with a different GP within the practice.
To be eligible for consideration, providers must have the capacity to:
- Provide a high quality one-hour education session for all practice staff on your area of specialisation.
- Engage in case conferences with a General Practitioner from the practice and associated allied health or nursing staff.
- Attend these half day events at regular intervals throughout the year, depending on your availability, to see multiple practices and return to previous practices to encourage continuous development.
The standard rate for delivery of the education component is $300 for a medical specialist per session and $200 for an allied health practitioner per session delivered. Travel costs can also be billed at the ATO rate.
The case conferences are to be billed to Medicare under the Multi-disciplinary Case Conferencing MBS items.
The in-reach education is delivered by a local medical specialist who can deliver share knowledge to  primary care professionals.Â
Through shared care appointments, case conferences, consultations, and structured learning presentations, you’ll guide general practice teams in building advanced skills and adopting innovative methods for managing chronic and complex diseases. Be part of a program that elevates local healthcare delivery and drives excellence in chronic disease management.
To learn more about the program, simply fill out the form above with your questions or details, and we will be in contact.
Ready to get started? Apply now!
How does the in-reach education model work?
The education is delivered using an in-reach model that has been implemented successfully in other regions across the country. A local medical specialist attends a general practice, along with supporting allied health staff or specialist nurses. The team provide a clinical education session for all the practice staff, then spend the afternoon with a single GP from the practice as they review patients requiring specialist input.
The patient gets the benefit of access to a specialist in their own general practice, while the doctor gets upskilled from the specialist in managing chronic and complex diseases.
The in-reach education model aims to:
Support the management of complex and chronic patients in general practice
Provide high quality specialist education to general practice clinicians and staff
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Build connections between local doctors and specialists to foster collaborationÂ
Utilise bulk billed Medicare items so there is no cost to the patient