To support ongoing capacity building across our region, these resources have been shared below for other practices wishing to implement new service models:
Bega Valley Medical Practice rolled out a Teen Clinic service into multiple practices including Bermagui Medical Centre, Curalo Medical Centre (Eden), Lighthouse Surgery (Narooma), Main Street Medical (Merimbula) and Kiama Medical Practice.
The clinics were provided with ongoing support and mentoring from Bega Valley Medical Practice.
Bulli Medical Practice implemented a nurse-led weight management clinic. Eligible patients had the opportunity to work with their doctor to reduce their weight and therefore improve their overall health and chronic disease management. By making the program nurse-led, it freed up doctors to see more acutely ill patients whilst still contributing to the management of these patients with chronic illnesses.
Bungendore Medical Centre incorporated a social worker in the practice to form part of the patient’s health care team.
There are multiple barriers to patients clinical outcomes in Bungendore due to inadequate access to social services.
The social worker developed and documented a system for identifying vulnerable patients most at risk as well as the appropriate local support services and referral pathways.
Jindabyne Medical Practice implemented a system using up-to-date secure technology to provide local families with access to top pediatricians in Jindabyne.
The specialist telehealth hub was one of 13 initiatives supported by COORDINARE, designed to build the capacity and capability of our region’s general practices to move towards a PCMH model of care.
Marima Medical Clinic (Goulburn) assessed osteoporosis as a chronic disease with a plan to reduce hospital admissions from preventable fractures and other complications.
Osteoporosis is a rarely identified chronic condition with two out of three Australians aged over 50 years having osteoporosis and osteopenia.
Moss Street Medical Practice (Nowra) piloted an integrated care approach for patients with chronic respiratory disease, given that hospitalisation rates amongst people living with COPD in the Shoalhaven are estimated significantly higher than the NSW state average rates.
Illawarra Family and Medical Centre (Wollongong) enhanced its nurse-led diabetes management program involving the creation of a ‘high risk’ patient stream. Patients with high-risk diabetes are at greater risk of developing co-morbidities than those with their condition under control. These patients are also at greater risk of poor health, increased hospitalisations and generally poorer quality of life. This project targeted these patients.
Lakeside Medical Practice (Warilla) implemented a nurse-led clinic to improve the level of care provided to diabetes patients through clinical review.
Many patients do not present frequently enough for proper management of their diabetes so this project enabled more focused review and discussion between GP and patient.
Market Street Medical Practice (Wollongong) included a consultant pharmacist and credentialed diabetes educator to focus on multidisciplinary care around medication review, especially for older patients who are often on a number of medications.
By focusing on de-prescribing and drug optimisation, this project aimed to reduce the number of potentially preventable hospitalizations.
Russell Vale Family Medical and Acupuncture Practice introduced bilingual trauma counselling for local Syrian refugee families with complex needs as a result of grief and loss, helplessness and fear from war and impacts of the refugee experience. The project aimed to improve the continuity of care through better engagement and understanding of the patient.
Sharp Street Surgery implemented a telehealth support service for patients discharged from hospital. Patients often get discharged from hospital with only a few days’ supply of newly started medication. At-risk patients like elderly patients or patients with disability are often worse affected by multiple comorbidity. The project aimed to check on patient wellbeing, review any new and existing medications; and confirm or arrange appointments and referrals.
Find out more about the outcomes of the project by reading the University of Wollongong evaluation report or by contacting your Health Coordination Consultant.
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