For people living in small rural communities, navigating the health system can sometimes feel overwhelming. Access to services is often limited and knowing where to start can be difficult – especially for people managing chronic conditions.
At a rural general practice in the Isaac region, however, a strengthened approach to chronic disease management is making a meaningful difference for its patients and the local community.
Since the launch of the Chronic Conditions Primary Care Package in July 2025, Middlemount Medical Centre has seen strong growth in engagement with chronic disease services.
The number of non-First Nations patients receiving the service for the first time increased by 590 per cent – rising from 10 patients in the first quarter to 69 by the third quarter.
First Nations patient access also increased, with health assessments rising by 313 per cent (from 16 to 66), while GP management plans increased by 218 per cent (from 22 to 70).
At the centre of this success is Amanda Porritt, the practice’s Chronic Disease Care Coordinator.
Originally from Melbourne, Amanda is an experienced nurse who previously managed chronic condition programs in Victoria.
Since joining Middlemount Medical Centre, she has helped introduce new systems and processes that are strengthening how the practice supports patients living with chronic illness.
“The program is very patient centred,” Amanda said.
“It’s about understanding each person’s needs, helping them understand their condition and empowering them to be involved in decisions about their own care.”
Her day-to-day work includes developing care plans with patients, helping them navigate the health system, coordinating services, and building strong connections with allied health providers across the region.
Amanda also works closely with the practice team to ensure patients are identified early and receive the support they need.
“When I stepped into the role, chronic disease management was new for the practice. We introduced health assessments and care plans, and spent time educating staff and GPs about the program,” she said.
Patients now see Amanda before their GP appointment so she can update key health information such as blood pressure, weight, and other clinical indicators.
This approach helps identify opportunities for preventative care and ensures patients receive the most appropriate support.
Amanda believes the program’s success is due to several key factors – including dedicated time with patients, stronger systems and processes, and building trusting relationships with both patients and doctors.
“Having a dedicated person in the role and protected time to consult with patients has made a huge difference,” she said.
The program is supported by funding from Northern Queensland Primary Health Network (NQPHN), which has enabled the practice to establish the role, have training opportunities, and implement digital tools to support patient care.
The impact is already being seen in patient outcomes. Amanda has observed improvements in clinical indicators such as blood sugar levels, cholesterol, and blood pressure, as well as healthier lifestyle choices and greater patient engagement in self-monitoring their health.
For many patients, the biggest change has been having a trusted point of contact at the practice.
“In a small rural community where navigating the health system and having access to services can be challenging, Amanda has been an advocate for me and other patients,” said local patient Michael Graham.
“She provides clear advice and connects us with the right services and care team. She has made a complex journey feel manageable and supported. Her dedication has made such a difference in our community.”
Another patient, long-term Middlemount resident Monique Newton, said the program had improved access to services often taken for granted in larger centres.
“Living in a rural or remote community, we don’t normally have access to services which are considered normal in metropolitan towns and cities,” Ms Newton said.
“To have access to a nurse regarding general health enquiries has been an invaluable service.
“I now have subsidised allied health services I wasn’t aware of and have been able to use them with my physio.
“This service has had a beneficial and positive effect on our community.”
For Amanda, the most rewarding part of the role is the connection she has built with patients and the community.
“What I enjoy most about living and working in a rural town is the strong sense of community,” she said.
“I love building genuine relationships with patients and seeing the impact of my work beyond the clinical setting.
“It feels meaningful and connected in a way that’s hard to replicate in larger cities.”
She also credits the supportive team at Middlemount Medical Centre for helping the program succeed.
“I feel incredibly lucky to work alongside such an amazing and caring team,” she said.
“Everyone brings something unique – compassion, humour and resilience – and it creates a positive environment that makes it easy to come to work every day.”
As the program continues to grow, Middlemount Medical Centre’s experience highlights how dedicated chronic disease coordination can strengthen care, empower patients, and improve health outcomes in rural communities.
Amanda Porritt, the practice’s Chronic Disease Care Coordinator.