Chronic Care for Aboriginal People (CCAP)

The NSW Health Chronic Care for Aboriginal People (CCAP) Program is a Statewide program aimed at improving the health of Aboriginal people who have a chronic disease.

The main components of CCAP are:

  • Improving the identification of Aboriginal people
  • 48 hour follow up call/home visit when patients with chronic conditions are discharged from hospital
  • Culturally competent care to the Aboriginal community
  • Aboriginal Chronic Care Worker
  • Aboriginal health community nursing service
  • Chronic Disease Management-Connecting Care in the CommunityChronic Disease Rehabilitation.

CCAP has a follow up service where patients receive a phone call within 48 hours after discharge to discuss:

  • Whether the patient is managing at home
  • Medications
  • Further services that may be required
  • Further medical appointments that may be required.

The CCAP is delivered by the MNCLHD Community and Allied Health Team.

Aboriginal health community nursing service

Provides direct nursing care, supportive visits, assessment, education on chronic diseases, outreach clinics and referral to other appropriate services.

48 Hour Follow Up for Chronic Conditions

Asks patients about:

  • Management at home
  • GP appointments
  • Medication
  • Services
  • Understanding your illness and hospitalisation
  • Enrolment opportunity into the Chronic Disease Management Program.

Connecting Care

An ongoing Care Coordination and Health Management program linked with Chronic Disease and other programs. Benefits are regular phone contact or assistance with education if needed and combined care.

Chronic Disease Rehabilitation

  • These programs are usually 2 hours per week for 6-8 weeks
  • Includes education on nutrition, medications and gentle exercise
  • Improves quality of life.

Aboriginal Chronic Conditions Network

The  Aboriginal Chronic Conditions Network (ACCN)  works to improve the experience and delivery of healthcare for Aboriginal people with chronic conditions in NSW, find out more at the NSW Agency for Clinical Innovation.


Services available at these locations

Coffs Harbour

Cofs Harbour Community Health
345 Pacific Highway
Coffs Harbour NSW 2450

Referrals via Intake
Phone 02 6656 7646
Fax 02 6656 7610


Kempsey Community Health
Polwood Street,
Kempsey, NSW, 2440

Aboriginal Chronic Care Worker
Phone 02 6562 0373
Fax 02 6562 8116

Registered Nurse – Chronic Care for Aboriginal People
Phone 02 6562 0526
Fax 02 6562 8116
Email –

Port Macquarie

Population Health, Planning and Performance
Morton Street,
Port Macquarie, NSW, 2444

Aboriginal Chronic Care Worker
Phone 02 6589 2100
Fax 02 6589 2160

Registered Nurse -48hr Follow Up
Phone  02 6588 2750
Fax 02 6588 2837