This initiative provided an opportunity for general practices to strengthen their resilience by implementing models of care that are focused on patients most at risk of poor health outcomes in the context of COVID-19 and / or bushfire recovery.

Applications which sought to improve service models to support patients who are considered to be part of the 'rising risk' cohort were strongly encouraged. We were particularly interested in service models that work with:

  • those with long term / uncontrolled diabetes: increase in number of patients who are receiving regular glycemic index monitoring and demonstrate clinical improvements
  • patients with chronic renal disease: increase in number of patients with improvements in glomerular filtration rate
  • patients with hypertension: increase in number of patients whose blood pressure is regularly checked and subsequent reduction
  • patients with chronic circulatory disorders: increase in number of patients who have improvements in cardiovascular markers. Implementation of self-management initiatives with patients
  • children requiring immunisation
  • influenza vaccination clinics; and/or those with a number of comorbidities.

Practices had the opportunity to develop and implement new or enhanced service models. Alternatively, practices could choose to adapt and implement a predefined model of care developed by local practices through previous funding rounds.

Practices also had the opportunity to use the Patient Activation Measure (PAM) tool at baseline and completion of the implementation of their model of care.