Primary Care Impact Grants - Supporting Chronic and Complex Disease Management
Multidisciplinary Team Care Grants: Awardees
Healthy North Coast has awarded multiple rounds of the Multidisciplinary Team Care 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.
Multidisciplinary care brings together patients and health professionals from different specialties to address all aspects of a patient’s health. This flexible, collaborative approach adapts to the unique needs of each individual, ensuring high-quality, personalised care.
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 Multidisciplinary Team Care grants was evaluated in February 2025. There were 13 applications received, of which seven were awarded. The second round of Multidisciplinary Team Care grants was evaluated in April 2025. There were 11 applications received, of which 4 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.
All Together Therapy, Port Macquarie
The Hastings Early Childhood Health & Development Integration Program aims to improve the early identification and intervention of developmental, behavioural, and health concerns in children aged 0–5 years across the Hastings region. By fostering strong partnerships between general practitioners and allied health professionals, the program will deliver a collaborative, family-centred model of care that ensures timely, equitable access to early intervention services. Through this integrated approach, we aim to reduce the gap between concern and support, enhance developmental outcomes, and empower families with knowledge and resources to support their child’s growth.
The Multidisciplinary Team: GP, Occupational Therapist, Speech Pathologist, Dietician & Physiotherapist.
Planned Outcomes : Increased rate of early developmental screenings, improved developmental progress, improved caregiver confidence & increased access to services.
Multidisciplinary Team Care Grants - Round 3 Awardee
Evaluation Summary
A strong multidisciplinary program with an established allied health team working to support local general practitioners.
Grant Awarded: $75,000
Lismore Music Therapy, Lismore
The Early Childhood Foundational Support program delivers multidisciplinary therapy and support within early childhood education settings for children with developmental delays, disabilities, and neurodiversity (including ADHD, ASD, and GDD). It integrates music therapy, speech pathology, and nursing to develop skills, enhance participation, and foster collaboration among families, educators, healthcare professionals, and support staff.
The Multidisciplinary Team: GP, Music Therapist, Speech Pathologist, Practice Nurse and Medical Specialists.
Planned Outcomes : Improved health outcomes, increased access to allied health services, increased skills and knowledge among educators, support staff, GPs, etc to support non-NDIS children with identified developmental concerns/delays/disability and/or neurodiversity, improved communication between key sectors.
Multidisciplinary Team Care Grants - Round 3 Awardee
Evaluation Summary
An exciting program utilising creative therapies to reach the early childhood population. The program presents an opportunity to highlight the need for coordination between general practice, allied health and the NDIS to secure the best possible outcomes for children in our community.
Grant Awarded: $75,000
The Grange Family Medical Centre, Port Macquarie
The initiative provides structured cardiovascular risk screening, care planning, and ongoing allied health support, with exercise physiology, nutrition, and nurse-led monitoring working alongside GPs to reduce risk factors and prevent avoidable hospitalisations.
The Multidisciplinary Team: GP, Practice Nurses, Nutritionist & Exercise Physiologist.
Planned Outcomes : Reduced cardiovascular risk scores, improved clinical measures (BP, BMI, lipid profile, HbA1c), improved health related quality of life.
Multidisciplinary Team Care Grants - Round 3 Awardee
Evaluation Summary
A clear model to target a specific high risk patient group with proven clinical interventions.
Grant Awarded: $45,800
WorkforceIQ Holdings
To improve management of chronic pain in general practice by delivering a structured, accessible, and evidence-based education and coaching program. It aligns with GP Chronic Condition Management Plans (GPCCMP) to reduce hospitalisations, strengthen patient self-management, and improve outcomes, particularly in small and rural practices.
The Multidisciplinary Team: GP, Psychologist, Physiotherapist, Dietician, Exercise Physiologist, Sleep Consultant & Occupational Therapist
Planned Outcomes : Improved health related quality of life, improved functional capacity, reduced pain intensity, improved self-management, decreased reliance on acute care.
Multidisciplinary Team Care Grants - Round 3 Awardee
Evaluation Summary
A flexible model of multidisciplinary management for chronic pain that supports areas of low access to allied health care.
Grant Awarded: $75,000
PKG Medical Centre, Tweed Heads
The PKG Medical Centre program improves chronic disease outcomes in Tweed Shire through a GP- and nurse-led multidisciplinary care model. It targets vulnerable adults living with diabetes mellitus, chronic airway diseases (asthma and COPD) and chronic kidney failure by coordinating bulk-billed services from allied health professionals. PKG Medical has also proposed conducting research on the program titled “Optimising healthcare delivery through coordinated chronic disease care to at-risk adults in the Tweed Shire region of Australia through a multidisciplinary, bulk-billed model.
The Multidisciplinary Team: GP, Dietician, Physiotherapist, Podiatrist, Diabetes Educator, Psychologists/counsellors, Pharmacists & Practice Nurses.
Planned Outcomes: Improved chronic disease clinical outcomes (HbA1c, Spirometry, GFR), reduced hospital admissions & improved patient satisfaction.
Multidisciplinary Team Care Grants - Round 2 Awardee
Evaluation Summary
A GP-centred MDT model of care maximising use of MBS funding with research level evaluation planned.
Grant Awarded: $74,750
Total Health Pottsville, Pottsville
This program integrates pharmacist-led medication reviews into the general practice setting to reduce medication-related errors, adverse effects, and avoidable hospitalisations in older patients with chronic disease. Delivered in clinic the initiative supports collaborative real-time decision-making through GP, nurse, patient, and pharmacist case conferences, streamlining care improving patient understanding and enhancing medication safety.
The Multidisciplinary Team: GP, Pharmacists & Practice Nurses.
Planned Outcomes: Reduced medication errors, reduced medication adverse effects, reduced hospitalisations due to medication error/adverse effects, improved patient health literacy & improved patient self-efficacy.
Multidisciplinary Team Care Grants - Round 2 Awardee
Evaluation Summary
A proposal that understood an unmet need in their community with a comprehensive plan to meet that need and record the outcome.
Grant Awarded: $75,000
Woodburn Health, Woodburn
This nurse-led program improves chronic disease prevention and management in Woodburn, a flood-affected and underserved community by offering structured assessments, targeted care planning, and regular follow-up with multidisciplinary input. The Chronic Disease Management and Intervention Program (CDMIP) empowers patients through health literacy, personalised care, and strong nurse-patient relationships to reduce preventable hospitalisations and support better long-term outcomes.
The Multidisciplinary Team: GP, Practice Nurses, Physiotherapist, Diabetes Educator & Menopause Support Nurse.
Planned Outcomes: Improved patient experience of care, improved access to services, improved health literacy, improved self-management of chronic disease & improved health related quality of life.
Multidisciplinary Team Care Grants - Round 2 Awardee
Evaluation Summary
Woodburn has very limited access to health services, and this proposal was aiming to bring services to the area and utilise them in an efficient way by providing MDT care.
Grant Awarded: $75,000
Yamba Doctors, Yamba
This program delivers dedicated, weekly diabetes education and movement-based support through a local educator and exercise physiologist at Yamba Doctors. It aims to improve health outcomes for patients with type 2 diabetes through ongoing, tailored care, including one-on-one sessions and group activities. With limited public support in the region, this program fills a critical gap and works to reduce hospitalisations and improve quality of life for patients with multiple chronic conditions.
The Multidisciplinary Team: GP, Practice Nurse, Diabetes Educator & Exercise Physiologist.
Planned Outcomes: Improved diabetes clinical outcomes (HbA1c), improved patient mental health, improved self-management & improve health-related quality of life.
Multidisciplinary Team Care Grants - Round 2 Awardee
Evaluation Summary
A proposal to provide diabetes services in an underserved community through education and active participation, supported by MDT case conferencing.
Grant Awarded: $65,820
Dr Tenell Holborow, Port Macquarie
Formalising MDT care for high-care and independent residents in aged care to improve chronic disease management, reduce hospitalisations, enhance quality of life, and support sustainable, bulk-billed care through structured, team-based interventions.
The Multidisciplinary Team: GP, Physiotherapist, Registered Nurse, Pharmacist.
Planned Outcomes: Improved health outcomes, reduced risk of falls and hospitalisation, enhanced health related quality of life.
Multidisciplinary Team Care Grants - Round 1 Awardee
Evaluation Summary
A clear aim to formalise existing ad-hoc multidisciplinary team care with regular case conferencing and technology to assist collaboration.
Grant Awarded: $40,000
Dunoon General Practice, Dunoon
Dunoon General Practice will implement a multidisciplinary frailty intervention program targeting patients aged 70+, aiming to reduce frailty progression and prevent avoidable hospitalisations. Using the Comprehensive Geriatric Assessment Toolkit, the program will assess frailty risk factors—physical fitness, nutrition, medication safety, and mental health—and then deliver tailored, evidence-based interventions through an MDT model. The practice will provide in-home, telehealth, and clinic-based care with no out-of-pocket costs for patients.
The Multidisciplinary Team: GP, Exercise Physiologist, Nutritionist, Pharmacist, Counsellor, Professional Story Writer.
Planned Outcomes: Reduced frailty score, reduced risk of falls and hospitalisation, improved mobility, enhanced health related quality of life.
Multidisciplinary Team Care Grants - Round 1 Awardee
Evaluation Summary
A clear understanding of their community’s needs with a detailed plan to meet those needs through coordinated multidisciplinary team care.
Grant Awarded: $65,040
Hastings Physio and Health and Werin Aboriginal Corporation, Port Macquarie
Hastings Physio & Health, in partnership with Werin Aboriginal Corporation and PCYC Port Macquarie, will deliver a culturally safe, group-based chronic disease prevention and management program for Indigenous Australians with or at risk of Type 2 diabetes.
The Multidisciplinary Team: GPs, Aboriginal Health Workers, Exercise Physiologist, Dieticians, Diabetes educators.
Planned Outcomes: Reduced diabetes risk score, reduced HbA1C, improved exercise tolerance, reduced falls risk, improved health related quality of life.
Multidisciplinary Team Care Grants - Round 1 Awardee
Evaluation Summary
An evidence-based, best-practice lifestyle intervention program supported by a multidisciplinary team in a culturally safe manner.
Grant Awarded: $75,000
Maclean Medical Centre, Maclean
Maclean Medical will deliver multidisciplinary team care targeting diabetes, heart disease, dementia, arthritis, COPD, and anxiety through care plans, education, telehealth, and coordinated case conferencing.
The Multidisciplinary Team: GP, Practice Nurse, Podiatrist, Exercise Physiologist, Diabetes Educator, Counsellor.
Planned Outcomes: Improved clinical outcomes, improved patient engagement and self-management skills, enhanced health related quality of life.
Multidisciplinary Team Care Grants - Round 1 Awardee
Evaluation Summary
A coordinated care model tailored to high-burden diseases, offering both individual and group interventions through in-person and virtual options to improve access, especially in rural and underserved areas.
Grant Awarded: $64,000
Maria Clinic, Casino
Maria Clinic will implement a structured, multidisciplinary program to improve outcomes for patients with Type 2 diabetes in the rural Casino community. The initiative integrates GP-led chronic disease management with allied health interventions to reduce complications and improve patient self-management.
The Multidisciplinary Team: GP, Exercise Physiologist, Diabetes Educator, Pharmacist.
Planned Outcomes: Improved HbA1c, increased physical activity, improved mobility, enhanced health related quality of life, patient reported experience measures.
Multidisciplinary Team Care Grants - Round 1 Awardee
Evaluation Summary
A strong MDT model of care that aligns with best practice management of diabetes.
Grant Awarded: $74,880
The Health Lodge Integrated Medical Centre, Byron Bay
Supporting families living in water-damaged homes following the 2022 Northern Rivers floods. It addresses chronic physical and emotional health impacts through a nurse-led, multidisciplinary care model.
The Multidisciplinary Team): GPs, Practice Nurses, Psychologists, and Occupational Therapists.
Planned Outcomes: Improved clinical outcomes, reduced risk of hospitalisation, enhanced health related quality of life, patient reported experience measures.
Multidisciplinary Team Care Grants - Round 1 Awardee
Evaluation Summary
Proposing a coordinated model of care to address the ongoing aftereffects of natural disasters with a detailed plan for evaluation and reporting of outcomes.
