Primary Care Impact Grants: Multidisciplinary Teams in Chronic Disease Management

Many people living with chronic and complex health conditions require support from a range of health professionals, but access to multidisciplinary care can be difficult, particularly in smaller general practices, Aboriginal Community Controlled Health Services, rural communities and areas experiencing disadvantage. The North Coast has a high burden of chronic disease, an ageing population, and rates of potentially preventable hospitalisations that exceed the state average for several chronic health conditions. The Multidisciplinary Teams in Chronic Disease Management program addresses these gaps by improving access to coordinated team-based care that supports people with complex health needs to receive the right care, from the right professionals, at the right time.

The program uses a grant-based commissioning model to support multidisciplinary healthcare teams within primary care settings. Funding is provided to eligible organisations to establish or expand team-based care initiatives that bring together general practitioners, nurses, allied health professionals, Aboriginal health workers and other healthcare providers. Programs are targeted towards communities, conditions and population groups with the greatest need and are selected through an assessment process that considers community need, equity, effectiveness, feasibility and sustainability. The model is designed to strengthen coordination of care, improve access to services and support better management of chronic and complex health conditions.

The program has been informed through extensive consultation with general practices, Aboriginal Medical Services, healthcare professionals, allied health representatives and Healthy North Coast’s Clinical Advisory Council. Stakeholders provided input into program priorities, outcome measures, assessment criteria and service design. Feedback highlighted the importance of locally designed multidisciplinary models that respond to community needs, improve access to care and support better health outcomes. Partnerships with allied health organisations, Aboriginal health services and healthcare providers continue to inform the delivery and ongoing refinement of the program.

The program provides grants to support the development and delivery of multidisciplinary team care services for people living with chronic and complex conditions. Funded activities may include care coordination, allied health services, nursing support, integrated care planning, chronic disease management programs, outreach services and innovative models that improve collaboration between healthcare providers. The program also supports data collection, outcome measurement and evaluation to ensure funded initiatives demonstrate improvements in patient outcomes and quality of life.

The program aims to improve the management of chronic and complex health conditions by increasing access to multidisciplinary team care and reducing barriers to coordinated services. It seeks to improve health-related quality of life, strengthen collaboration across the healthcare system and support better outcomes for people with chronic disease. Over time, the program aims to reduce avoidable hospitalisations, improve equity of access to healthcare services and establish sustainable models of integrated care that can continue to benefit North Coast communities into the future.