Our priority areas

Population Health


Northern Queensland Primary Health Network’s (NQPHN’s) population health priority objectives include prevention, promotion, and early intervention that are focused on the life stages.  

In the 2022-23 financial year, NQPHN supported primary health care providers to address factors impacting population health through increased engagement of practices using continuous quality improvement (CQI) information and resources dissemination, and systems integration.  

The key population health priorities for NQPHN include:  

  • maternal and child health  
  • chronic disease management and prevention  
  • sexual health  
  • Aboriginal and Torres Strait Islander health  
  • Greater choices for at-home palliative care  
  • older persons health.

Longer term, NQPHN’s commissioned programs will maximise health outcomes for people with preventable conditions across the different stages of life.  

By addressing the needs of North Queensland communities, and focusing on prevention and early intervention activities, there will be fewer preventable hospitalisations in the NQPHN region for people with chronic and vaccine preventable diseases.  

Combined, these activities will contribute to improved health outcomes for all population groups in the NQPHN region.

A selection of our Populations Health projects are highlighted below.

Our Region, Our People
Elderly Cairns man facing homelessness seeks help from Ozcare care finder service

A 76-year-old Cairns widow, feeling lonely and on the verge of homelessness, has found a home and happiness thanks to Ozcare and the care finder program.

Gary Boot* moved to Cairns from Western Australia following his wife’s passing to be closer to his only son.

However, after a few months of living in northern Queensland, Mr Boot’s son was offered a job in the mines in Western Australia and was relocated for work.

Feeling depressed and lonely, desperately missing his wife, and with his only accommodation in jeopardy, Mr Boot was at high risk of homelessness and sought help from Ozcare.  

Ozcare care finder Coordinator Kesa Strieby said within a matter of weeks, Mr Boot had a home in East Trinity and was receiving ongoing mental health support from a general practitioner and social worker.

“He is enjoying his new home, gets along with the owners, and has taken to walking along the beach. He’s also keen to go fishing one day,” she said.

“This was a positive and successful outcome, not only because we were able to find suitable and affordable accommodation by the beach for Mr Boot, but also because we were able to link him with other support services, which he also really needed.

“He’s extremely thankful and is happy that the care finder service was able to help him so quickly. He also said he’d highly recommend care finder to seniors on low income, who are stressed about their housing situation, and who need support services for independent living.”

The care finder program is funded by Northern Queensland Primary Health Network (NQPHN) and delivered by Ozcare to connect vulnerable older people to quality and appropriate aged care and other local services, including those experiencing homelessness, mental illness, and alcohol or drug dependence.

It is a free service and exists to provide intensive, face-to-face support for older persons who are isolated, or have no support person, and who are experiencing barriers to receiving the necessary support.

Mrs Strieby said through care finder, Ozcare helped older persons live their best life via compassionate, professional, and personalised community and health services.  

“We helped Mr Boot by personally viewing properties, which included independent living, supported accommodation, and hostels for seniors to find him accommodation that would best suit his needs,” she said.

“It was a great feeling when we could offer this older person accommodation at East Trinity in a two-bedroom fully furnished unit by the beach for a reasonable weekly rent that was suitable. We also assisted with the paperwork and relocation to his new home.

The care finder program helped Mr Boot register with My Aged Care to receive aged care and other supports on top of his tenancy.

Mrs Strieby said sadly Mr Boot’s story was not uncommon for older persons in the community.

“Every day through care finder we make a difference in people’s lives and help turn their vulnerability into happiness and a positive outcome,” she said.

“We help people who need assistance to reconnect and feel supported to continue to live independently and with dignity in a safe environment.”

* Name has been changed to maintain privacy.

Read more

Key projects

Care finder program

One of the Population Health initiatives is the care finder program, which forms part of the Australian Government’s response to the recommendations of the Royal Commission into Aged Care Quality and Safety.  

This initiative, which began in January 2023, was implemented to improve outcomes for vulnerable older Australians through improved coordination of support, improved rates of access to aged care services, connections with other relevant supports, improved rates of staying connected to the services post-service commencement, and improved integration between health, aged care, and other systems at a local level.  

NQPHN commissioned Footprints Community Limited, Aged and Disability Advocacy Australia (ADA) Australia, ABIS Community Co-operative Society Limited, Flinders Shire Council, and Ozcare to deliver the care finder program in the northern Queensland catchment.  

These providers have also established and maintained a network of 17 care finders who could provide face-to-face support for vulnerable older persons who:  

  • are isolated  
  • do not have a carer or family  
  • are experiencing barriers to accessing care due to communication, language or literacy challenges  
  • are having difficulty in understanding information and making decisions  
  • are reluctant to engage with aged care or government agencies.    

Care finders help clients:  

  • understand what aged care services are available to them  
  • register with My Aged Care  
  • provide support during assessment  
  • find and short list aged care providers in their area  
  • assist in completing forms  
  • understand aged care service agreements  
  • check in once services are set up  
  • problem solve challenges  
  • connect to other supports such as mental health, housing and homelessness, drug and alcohol services and community groups.    
Key statistics
care finder program lead providers
care finders who can provide face-to-face support for vulnerable older persons

Greater Choices for At Home Palliative Care

The below NQPHN initiatives are aligned with the Greater Choices for At Home Palliative Care objectives.  

Northern Queensland Aged and Palliative Care Interagency Steering Committee

The Northern Queensland Aged and Palliative Care Interagency Steering Committee was established to provide governance and codesign the delivery of the Greater Choice for At Home Palliative Care program across the northern Queensland catchment. This committee, which consists of 21 members, promotes system integration across sectors with membership from peak bodies, specialist palliative care, hospital and health services, pop-up palliative care, community palliative care services, and health community connectors.  

Compassionate Communities  

In collaboration with the Groundswell Project, NQPHN conducted a series of Compassionate Community Connectors train-the-trainer workshops and trained more than 300+ health community connectors from Weipa in the north to Moranbah in the south. These workshops provided ongoing awareness raising, advance care planning education, distribution of end-of-life care resources and local palliative care consumer journey maps, localised service mapping and identified gaps, activities related to socialising the conversation of advance care planning, death and dying, and effective signposting to identify and increase access to services.    

Northern Queensland Health Community Connectors (NQHCC) Network and Healthy End-of-Life Planning (HELP) app

Established in 2022 to provide ongoing supports and encouragement to health community connectors, this initiative promotes system integration where informal specialist palliative care services and other health services are engaged to present and network with health community connectors. This network meets every six weeks and provides opportunities for ongoing learning opportunities and linkages for community connectors to local primary care, palliative care specialists, and peak bodies. As required, NQHCC network members also create wrap-around informal supports to families affected by life-limiting illnesses in their community through the HELP app. The HELP app is a new initiative for community members in need to seek help from the health community connectors who become a circle of support assisting with collective care.    

Key statistics
members on the Northern Queensland Aged and Palliative Care Interagency Steering Committee
health community connectors from Weipa to Moranbah

After hours community consortium - telehealth

NQPHN’s After Hours Community Consortium – Telehealth is delivered by Royal Flying Doctors Service – Queensland Section (RFDS) and was implemented in 2022/2023 to address difficulties patients in rural and remote communities were having in accessing timely primary health care services.  

In April 2023, RFDS was announced as the lead telehealth provider for NQPHN to deliver afterhours telehealth services across the Cairns, Townsville, and Mackay regions, and continuing with its existing services in the Torres and Cape regions.  

In the last year, 6,766 unique clients accessed this service and, of that number, 32 per cent identified as First Nations.  

This program is a primary health care telehealth consultation liaison service to support patients with acute care needs who cannot wait for an in-hours GP service.  

It uses credentialled medical officers, with support from nurses and other allied health professionals who have specialised knowledge in rural and remote primary health care.  

Direct medical consultation is available through video, telephone, or radio communication for patients, isolated primary health care clinicians, such as remote area nurses, and Indigenous health workers to make it easier to provide and receive care.  

These telehealth services focus on the rural and remote communities across the NQPHN catchment, and this medical-based workforce can be augmented with support from nurses and other allied health professionals who have specialised knowledge of rural and remote primary health care.    

Key statistics
unique clients accessed the RFDS afterhours telehealth service
of these clients identify as First Nations

Our priority areas

Our priority areas