Evaluation of a multidisciplinary team care intervention for the management of chronic conditions in primary care

This research will evaluate a multidisciplinary team care pilot program which aims to build the capacity of primary care to support patients who have complex chronic condition/s. The intervention is targeted to 15 general practices and 60 Allied Health Providers within the catchment region of the Adelaide Primary Health Network. Each general practice will have GP-led and nurse coordination to: 1. Identify n=10-20 patients with a chronic condition 2. Undertake chronic condition screening and assessments with each patient 3. Recommend and develop an individualised chronic condition management plan for each patient, including referral of each patient to relevant/appropriate allied health professionals for multidisciplinary team-based support of their chronic condition, 4. Practices and allied health providers will engage in case conferencing for coordination of team care for each patient, as determined to be clinically indicated. 5. General practices and Allied Health Providers will be provided with digital technology hardware and software to support interoperability between medical records and communication systems, including secure messaging software and use of the national platform My Health Record. 6. General Practices and Allied Health Providers will engage in sharing their experiences and evidence-based clinical chronic disease management approaches in a 6-monthly community of practice, with facilitated support from Adelaide Primary Health Network. Three phases: Northern General Practices (4) and allied health providers (16) and patient recruitment (80) commences February 2026, Southern General Practices (6), and allied health providers (24) and patients (120) recruitment commences March 2026, Small and Solo General Practices (5), and allied health providers (20) and patients (50) commencing March 2026. Duration of intervention: 18 months post respective region program commencement data Patient recruitment: Will occur at the beginning of the project, hence each patient will be part of the respective intervention for 18 months. An adherence and fidelity checklist will be utilised. General Practices will provide 6-monthly progress reports regarding activity, patient interaction and retention.