Enhancing care coordination

Enhancing the role of nurses and other health professionals in providing more coordinated care to patients could reduce the demand for more general practitioners, and ensure patients are still receiving an appropriate level of care.

Find out more about our team based care initiatives below:

  • Nurse with patient who is using asthma puffer.

    Nurse-led clinics

    In the general practice setting, nurse-led clinics are an alternative model of care delivery where the nurse is the primary provider of care for the patient. This supports a team-based approach, and involves the GP and other members of the practice team.

    In 2020 we gave practices an opportunity to implement this model, to deliver enhanced care for patients at risk of poor health outcomes. Practices could also use the Patient Activation Measure (PAM) tool.

  • Female pharmacist, smiling and holding file.

    Pharmacy in the Practice

    In 2019, general practices applied for funding to integrate pharmacists into their care team. Woonona Medical Practice, Queen Street Medical Centre, Main Street Medical Centre, and Queanbeyan GP Super Clinic were successful.

    They worked with the pharmacist to assist in medication management, quality use of medicines and compliance, as well as supporting the medication of patients discharged from hospital.

  • Doctor and patient during telehealth appointment,

    Resilience in general practice

    In 2020, we invited practices to implement a quality improvement activity to strengthen their resilience in the context of COVID-19 and/or bushfire recovery.

    Increasing access to telehealth provides an opportunity for practices to modify their models of care, ensuring they can continue to provide quality care to those patients most at risk of poor health outcomes.

  • Male doctor and patient talking and laughing.

    Patient Centred Medical Home (PCMH)

    The PCMH model puts the patient at the centre of their care, ensuring they each have the care team they need. Watch this video to learn more.

    In 2017-18 our PCMH Innovation Project supported practices to develop and implement their own ideas for service improvement. Read an in-depth analysis, or learn more about the outcomes in the University of Wollongong evaluation report.

  • Male nurse, wearing surgical mask.

    Winter planning

    Every winter there is a rise in demand for health services and given the current pandemic this is further compounded.

    Proactively planning for winter and the flu season can help streamline processes, and ensure those most at risk of becoming unwell get the care they need.

    Find out more

Projects and models of care

To support ongoing capacity building across our region, the below resources and models of care have been shared for other practices wishing to implement new service models: