Dr Lisa Opie, practice owner at Thrive GP in Crookwell, says participating in LinkMyCare has already provided benefits for patients and the practice. 

The LinkMyCare COPD program aims to improve the care that patients with Chronic Obstructive Pulmonary Disease (COPD) receive. The program is a collaborative initiative between COORDINARE, Southern NSW (SNSWLHD) and Illawarra Shoalhaven (ISLHD) Local Health Districts. COORDINARE has commissioned five general practices to deliver the LinkMyCare program and aims to bring on a total of 18 over three years. There is currently an opportunity for additional general practices to express interest in participating. 

Benefits to the general practice and patients 

Dr Opie said the practice applied to join LinkMyCare for several reasons.

“We could see benefit for our patients; to access more coordinated care, lung function testing, education and support to manage their COPD better. And for us as a general practice to implement systems that we could use in chronic disease care management is also beneficial.  

“For example, the program links us with hospital discharges, uses care plans, and utilises additional experts like a respiratory scientist. Similar elements could be used in chronic disease care management for other conditions,” added Dr Opie. 

Program resources 

“There are various roles in this program, a respiratory scientist is doing spirometry, plus when patients are discharged from hospital a local health district nurse alerts our practice, which hopefully will ensure a good transfer of care. 

“Within our practice, all of us GPs are involved in looking after our own patients as they progress through the program. LinkMyCare provides funding to allow our practice nurses to assist with patient education and care planning, to sit with patients and drill down into action plans and things like that. 

"Importantly, our practice nurses are involved from the beginning to the end, so they can be another point of contact for patients. For instance, if a patient can't immediately talk with me, they will be able to ask to speak with the practice nurse who will know enough about their COPD to be able to assist, most of the time,” said Dr Opie. 

Equipping patients with education 

"The program is demonstrating that a lot of our patients are very interested in learning more about their COPD and about their health. We've had the respiratory scientist come for a day and that was brilliant to be able to offer such excellent care and assessment. It is also great for the practice to be able to manage our workload better. If patients are managing their own health and they know when to come, they're not coming too late but they're also able to self-manage the early stages of their illness. 

“Equipping patients to manage their own health is really good, it means they're not waiting, even until the next day or after the weekend to start whatever treatment they need, it ensures their care isn’t delayed," said Dr Opie.

Future directions 

“My hope is that it continues as our ongoing plan of looking after COPD and over the time of this project we will see even more benefits for patients. As COPD patients are often in hospital during winter, I'm hopeful that as we come into winter, we'll start to see that ongoing benefit, especially the connection on discharge from hospital. The goal is to give them seamless care so that they've got their self-management, but they are also linked in with the other people in the community who can help them in a seamless way. 

"I'm also hopeful that will permeate out into our chronic disease management for other conditions, obviously not all the specific elements but using different parts of the community and connecting in different resources for patients. 

“It has been a good a self-reflection tool for us as a practice, to look at what we've doing now and improve on it,” added Dr Opie. 

Practices can submit an Expression of Interest in LinkMyCare here.

More information about the LinkMyCare program is available here.