LinkMyCare - COPD | COORDINARE - South Eastern NSW PHN

LinkMyCare - COPD Program

“COPD is a serious chronic health issue for our region. Patients with COPD need significant support from their general practice teams, and need to access services with allied health providers and hospitals.

The LinkMyCare program will encourage active involvement from patients and members of their practice team and will facilitate integration with allied health and hospital services to ensure the right care at the right time.”

- Dr Katherine Michelmore, Illawarra GP and Medical Director at COORDINARE.

Care Pathway Flowchart

Coordinare, in partnership with the Illawarra Shoalhaven Local Health District, and the Southern NSW Local Health District are supporting a Multi-Disciplinary Team (MDT) approach to the management of COPD within the community. 

The LinkMyCare – COPD program will provide funding to a range of providers to deliver services to patients close to their home, at no cost to the patient, that should help avoid hospital visits.

The program is being funded through NSW Health. It is expected that the program will improve patients’ quality of life, reduce hospital admissions and length-of-stay (LOS) and assist providers to better work collectively to support patient health outcomes. 

Implementation timeline

EOI and onboarding

Late July 2024

Engage the first nine practices and begin the onboarding and commissioning process.
Community transition service

August 2024

LHDs commence service.
First patients enrolled

Late October 2024

Practice staff of tranche one reach out to targeted cohort.

Pulmonary Rehab

Late 2024

Services commissioned and enrolling patients.
Tranche two practices

January 2026

An additional eight practices join the pathway.
Exit Collaborative Commissioning

June 2027

South Eastern NSW

First tranche of General practice EOIs

The map shows the catchment for COORDINARE - South Eastern NSW PHN, with the blue ticks highlighting the areas of focus during first tranche of General Practice EOIs.

Key resources

COPD Annual Cycle of Care

The COPD annual cycle of care includes three practice appointments, one held every four months.

Read more
Collaborative Commissioning Care Pathway

The purpose of this report is to outline the proposed care pathway, which has been developed through a co-design process.

Read more

“COPD is a serious chronic health issue for our region. Patients with COPD need significant support from their general practice teams, and need to access services with allied health providers and hospitals. The LinkMyCare program will encourage active involvement from patients and members of their practice team and will facilitate integration with allied health and hospital services to ensure the right care at the right time.”

- Dr Katherine Michelmore, Illawarra GP and Medical Director at COORDINARE.

"Our work with Coordinare PHN has seen active engagement in many of our transformational programs of work in areas such as Collaborative Commissioning, remote patient monitoring, and population health. Our Collaborative Commissioning work in partnership with PHN and ISLHD in particular is shaping to be highly impactful for us in supporting us to manage COPD patients across the care continuum, and we’re excited to see this work progress in the near future."

- Chin Weerakkody, Manager Virtual Care, Programs & Innovation, Integrated Care & Allied Health, Southern NSW Local Health District.

Further information

You can read more about Collaborative Commissioning and the statewide program on the NSW Health website.

Find out more

LinkMyCare - COPD Program

Care Pathway Flowchart

Implementation timeline

EOI and onboarding

Community transition service

First patients enrolled

Pulmonary Rehab

Tranche two practices

Exit Collaborative Commissioning

South Eastern NSW

Key resources

COPD Annual Cycle of Care

Collaborative Commissioning Care Pathway

Further information