The aim of our program is to improve access to health services and support a client centred approach to chronic disease prevention, treatment and management with consideration of the physical and cultural components of their wellbeing. We offer Health assessment screening (715’s) and provide opportunities for screening to enable early detection of those with or at risk of developing a chronic condition, support access to specialist services through our ITC Program (requirements Health assessment and a GP Management plan), improve health literacy and empower individuals to set their own goals and self-manage their conditions. 

Our multi-disciplinary team consists of Aboriginal Health Workers/Practitioners, Nurses, General Practitioners, Specialists Physicians and Allied Health professionals. Our attending specialists are Cardiology, Endocrine, Geriatric and Renal. Our Chronic Disease team aim to enhance the care provided for Aboriginal people with chronic illness, improve their quality of life and that of their carer’s and reduce co-morbidities and hospital presentations by delivering and assisting in the delivery of chronic disease services such as screening, education and specialist services to Aboriginal people suffering from chronic illness within the Aboriginal Communities from Kempsey to Nambucca Heads.   

We do this by offering: 

• Health Assessment (715) 

• General Practitioner Management Plan/Team Care Arrangements (GPMP/TCA)