Multidisciplinary care making a difference across the region

Multidisciplinary teams (MDT) programs are transforming the way care is delivered across the Darling Downs and West Moreton region, helping residents manage their health with the support of a coordinated team of healthcare professionals.  

Commissioned by the PHN, these programs bring together GPs, nurses and allied health professionals to support people living with mental health conditions and chronic conditions.

A broad range of programs has now been established across the region, including:  

• Goondiwindi Falls Prevention Program
• Inglewood Chronic Disease Lifestyle and Diabetes Program
• Dalby Link-Worker Navigation Model
• Tara Echocardiography Clinic
• Lockyer Valley Chronic Pain Clinic
• South Burnett Osteoarthritis Screening Program
• Indigenous Wellness Connect (Goondiwindi cross-border region)
• Toowoomba Endometriosis and Pelvic Pain Clinic

Country Care Connect GP-led Mental Health Clinics (currently being established in Goondiwindi, Western Downs, Lockyer Valley and Somerset).  

The PHN plays an important role in enabling MDT programs, working with general practices to enhance service delivery and foster collaboration. Through quarterly MDT Community of Practice meetings, providers also come together to connect, share learnings and explore new approaches to improving patient care.  

Darling Downs and West Moreton PHN CEO Lucille Chalmers said GP-led multidisciplinary care is helping deliver more coordinated, person-centred support for people across the region.

“These programs demonstrate the power of coordinated, locally-led care in helping people better manage their health and wellbeing,” Ms Chalmers said.

“By enabling a team to come together, we can help ensure people with complex and chronic health needs are connected to the right care, closer to home.

One local resident who benefited from this approach is Margaret, who was referred to a six-week multidisciplinary rehabilitation program at Tara Medical Centre.  

Living more than 100 kilometres from the nearest town and managing multiple chronic health conditions, Margaret was looking for ways to improve her health and maintain her independence. Following a comprehensive assessment, she joined a group program close to home that combined strength and balance exercises, falls prevention education and nutrition support.

After six weeks, Margaret achieved significant improvements in her mobility and balance, with her Timed Up and Go score improving from 9.10 seconds to 7.35 seconds and her Berg Balance Score increasing from 51 to 56. Her self-rated health and wellbeing also increased from 60 per cent to 80 per cent.

Alongside the clinical benefits, the program provided an opportunity to connect with others and build confidence in a supportive environment.  

“I enjoyed the camaraderie with the group. The exercises were enjoyable and functional, and I felt safe. The support helped me change my diet and build confidence,” Margaret said.

Tara-based general practitioner Dr Tim Lloyd-Morgan said Margaret's experience reflects the impact MDT programs are having across the region.

“These programs are about more than managing health conditions,” Dr Tim said.

“By bringing together the right expertise and support, and listening to what matters most to patients and communities, we're helping people improve their health while also building confidence, independence and stronger connections to those around them.”