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Multidisciplinary Team (MDT) Program

The MDT Program improves access to coordinated allied health services for people living with chronic pulmonary, cardiac or diabetes conditions in Darwin and Alice Springs.

About

Many people with chronic health conditions face financial barriers that prevent them from accessing the care they need. This program removes those barriers by providing free allied health services to eligible clients who would otherwise be unable to afford them.

By bringing together a team of allied health professionals, the program supports a multidisciplinary approach to managing pulmonary, cardiac and diabetes conditions in primary care. The aim is to improve health outcomes through coordinated, client centred care.

Key Program Aims:

  • enhance access to multidisciplinary team care
  • reduce the cost barrier for individuals in need of coordinated care
  • strengthen connected, team-based care within primary care settings
  • empower clients to better manage their chronic health conditions
  • reduce hospitalisation rates in the Northern Territory
  • improve client health and quality of life outcomes in Darwin and Alice Springs.

MDT program services

System Navigator
The System Navigator acts as the central point for referral management. They coordinate and allocate services, working with general practices, allied health providers and MDT support services.  The System Navigator is also responsible for keeping the referring GP informed of each client’s progress throughout the program.  

MDT Allied Health Providers
Allied Health providers deliver clinical services to clients, and report progress and outcomes back to the referring GP. They also work with the System Navigator to support care coordination and access. Eligible providers will be registered with and funded by NT PHN to deliver services within program scope.

MDT Support Services
The support services are group activities that complement MDT allied health services (e.g. group low intensity exercise sessions). Support services are designed to improve how participants manage their health and function day to day. Participants who meet program eligibility criteria can access the support service programs through the System Navigator.

General Practitioners (GPs) will be able to refer eligible clients to the program by completing and sending the following documents to the System Navigator:

Once the GP refers a client to the program, the System Navigator provides care coordination. They work directly with the client to arrange access to the right services. The client will be supported towards the goal of slowing or preventing the progression of their condition and supporting their overall wellbeing.

To be eligible for the program, the client must:

  • live in Darwin or Alice Springs regions and hold a valid Medicare card 
  • have diabetes, pulmonary disease, and/or cardiac disease
  • be at high risk of escalation or progression of one or more of their chronic conditions in the next 24 months  
  • hold a current Health Care card, Low Income Health Care card, Pension card, or meet other specified financial hardship criteria*
  • have support from their GP to participate in the program.

* Financial hardship criteria

  • someone who has recently lost employment but does not yet have the required documentation
  • someone who is experiencing family violence
  • someone who is experiencing homelessness, housing insecurity or living in crisis accommodation.

Eligible clients can access:

  • Up to 10 allied health sessions at no cost
  • Coordinated care and appointment support from the System Navigator
  • Choice of allied health providers registered with the program
  • Access to a Support Service, such as a group physical activity program

MDT Program Allied Health Service providers are responsible for delivering clinical services to clients living with diabetes, cardiac disease and/or pulmonary disease in the Darwin and Alice Springs regions. Providers will communicate care progress and outcomes to referrers and collaborate with System Navigators as needed.

Allied Health Service Clinical Types in Scope for the MDT Program:

  • Podiatry
  • Physiotherapy
  • Dietetics
  • Diabetes Education
  • Occupational Therapy
  • Exercise Physiology
  • Psychology
Profession Scope and intended health care goals*
Cardiac disease Pulmonary disease Diabetes
Podiatry Management of arterial and venous insufficiency secondary to cardiac disease Not applicable Management and prevention of diabetes complications of the feet
Physiotherapy Pain management, increased mobility, strength and independence Therapy for management of exacerbations, including breathing techniques for self-management and quality of life Pain management, increased mobility, strength and independence
Dietetics Dietary approaches for good heart health Maintaining appropriate energy and protein intake for preventing frailty and improving and quality of life Dietary approaches for maintaining BGLs and HbA1C within healthy ranges
Diabetes education Not applicable Not applicable Enhanced self-management such as lifestyle changes, medication management, self-monitoring BGLs
Exercise physiology Individualised exercise prescription for cardiac rehab, maintenance of musculoskeletal health, cardiovascular health and other health goals Individualised exercise prescription for improved lung function, aerobic endurance and prevent muscle loss Individualised exercise prescription for maintenance of musculoskeletal health, cardiovascular health and other health goals
Occupational therapy Facilitate functional participation in daily activities and enhance quality of life through tailored interventions addressing personal, environmental and task-related barriers
Psychology Provide assessment and tailored interventions to support treatment adherence, lifestyle change, and management of chronic health conditions

*This is not a comprehensive list of intended health goals; other health goals may be defined by referrer in the context of other health conditions of program participants.

Only registered MDT Allied Health Providers are authorised to deliver services under the MDT Program. Providers must have completed the formal NT PHN onboarding and assessment process and be approved by NT PHN to participate in the program.

How to register: Please send an email with your expression of interest to MDTprogram@ntphn.org.au

In some cases, eligible clients may nominate a preferred provider who is not currently part of the MDT provider pool. In such instances:

  • The System Navigator must refer the nominated provider to NT PHN.
  • NT PHN will manage and coordinate the onboarding process directly.