What have we achieved?

  • 10 out of 12 of our clusters regions were represented in the project, providing good spread across the catchment
  • Over $550K of funds was dispersed primarily on implementing practice model of care but also to support the upskilling of primary care staff across the region
  • 13 separate projects were funded across 17 general practice sites
  • 3 of the projects involved a partnership approach with LHD, enhancing our relationships and  encouraging general practice to think about their role in the healthcare neighborhood
  • 7 of the projects focused on at risk or vulnerable groups
  • 5 of the projects incorporated allied health
  • Over 90 general practice staff were upskilled as part of the project including the
    • GP leadership program, the Medical Practice assistant,  health coaching / motivational interviewing, as well as clinical training specific to individual projects e.g. spirometry training; and
  • in the 9 months the pilots were live the projects reached over 650 patients.

A summary of the individual projects can be seen below:

  • 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 our local families’ access to top pediatricians in Jindabyne.
  • 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.
  • Dr Chandrans Surgery (Albion Park) – developed a nurse-led respiratory disease management clinic to assist patients in better managing asthma and COPD, especially in the lead-up to winter.
  • 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 hopitalisations and generally a 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 hospitalisations.
  • Queen Street Medical – developed a transfer document that sits alongside the Shared Health Summary in My Health Record as a statement of a person’s medical condition, their premorbid function and their past-history. By drawing together the needs of the patient, GP, Residential Aged Care Facility and hospital the project aimed to increase efficiency through enhanced accessibility of relevant documentation; and improve patient outcomes and patient experience through enhanced care coordination.
  • Russell Vale Family Medical and Acupuncture Centre – 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 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. This support has the potential to facilitate faster return to optimal health and reduce the chance of hospital readmission.

For more information about the outcomes of the project you can view the University of Wollongong evaluation report or contact your Health Coordination Consultant.