Chronic Disease Management
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.
Join us in building a more connected, high-quality, and accessible health system for the North Coast community.
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
View or download the Specialist In-Reach Education in Chronic and Complex Disease Management Expression of Interest
In Reach Chronic Disease Specialist Contact Form
Program details
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.
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.
What topics are available to be delivered as In-Reach Programs?
We are currently offering In-reach Education and Case Conferencing on Diabetes, Chronic Kidney Disease, Harm Reduction and Palliative Care.
Our focus for the Specialist In-reach Program is chronic disease management and better supporting patients with a life limiting illness. If you are a medical specialist, specialist nurse or supporting allied health professional with a topic you’d like to provide in-reach education on, please get in touch via the form below.
What other insurances am I required to have?
You are required to have Public Liability and Professional Indemnity Insurance to the amounts outlined below.
- Public Liability Insurance – You must have a minimum of $10 million cover per occurrence and $20 million in aggregate.
- Professional Indemnity Insurance – You must have a minimum of $10 million cover per occurrence, and the policy must include reinstatement of the limit.
The EOI form asks for WorkCover documentation, am I required to have this?
WorkCover is required for employers who employ workers. If you are a sole trader or individual without employees, you are not required by law to have WorkCover.
If accurate to your circumstances, for this question, please simply upload a document saying ‘I am a sole trader or Individual and am not required by law to obtain WorkCover’.
Working with Children Checks (WWCC)
A WWCC is needed for child‑related work, which involves services specifically for children, where face‑to‑face contact with children is a usual part of the role and more than incidental.
As the majority of the case conferences are delivered to adults over 18 years of age, and any minors would have a parent/guardian present, you are not required to have a WWCC to deliver in-reach education and case conferencing.
If you are proposing an in-reach topic to us that is specifically child-related then we would request a WWCC.
What are the MBS Item Numbers for the Multidisciplinary Case Conferencing?
Providers are eligible to use the below numbers when participating as a member of a multidisciplinary case conferencing with 2 other formal care providers of different disciplines.
- General Practitioners: MBS Item 743 (40 mins+)
- Medical Specialist / Consultant Physician: MBS Item 828 (45mins +)
- Allied Health Professionals (including Nurse Practitioners): MBS Item 10959 (40 mins+)
These item numbers are subject to change, please check the Medicare Benefits Schedule regularly for accurate information.