Team based care

Pharmacists in general practice is an initiative in which a non-dispensing pharmacist is included in the healthcare team of a general practice, with the aim of providing medication-related clinical and education services to patients.

13 practices were part of a project designed to build the capacity and capability of our region’s general practices to move towards a PCMH model of care.

Further information can be found at the following links:

• Case study - Market Street Medical Practice, Wollongong
• Model of care - Market Street Medical Practice, Wollongong
• Case Study - Woonona Medical Practice
• Case study - Main Street Medical Centre, Merimbula

Jindabyne Medical Practice implemented a system using up-to-date secure technology to provide local families with access to top pediatricians in Jindabyne.

The specialist telehealth hub was one of 13 initiatives supported by COORDINARE, designed to build the capacity and capability of our region’s general practices to move towards a PCMH model of care.

Further information can be found at the following links:

• Case study
• Model of care

COORDINARE funding enabled a consultant pharmacist to be embedded at Woonona Medical Practice, with a particular focus on the management of patients prescribed opioids. You can read the case study here.

The following resources were developed by Woonona Medical Practice, to support general practices implementing opioid de-prescribing:

• Medication stewardship in general practice implementation guide
• Opioid agreement - trial
• Opioid agreement
• Opioid patient handout
• Opioid policy and protocol template

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. 

Further information can be found at the following links:

• Case study
• Model of care

Marima Medical Clinic (Goulburn) assessed osteoporosis as a chronic disease with a plan to reduce hospital admissions from preventable fractures and other complications. This model provided group education sessions led by nurses, and involving GPs and allied health staff.

The aim was to educate and empower patients over 70 years of age, about how to recognise and/or avoid the health complications of osteoporosis.

Further information can be found at the following links:

• Case study
• Video
• Model of care

Moss Street Medical Practice (Nowra) were able to pilot two respiratory clinics; one focused on asthma and the other on Chronic Obstructive Pulmonary Disease (COPD).

At each clinic, a series of patients were seen individually by their care team which consisted of their GP and primary health care nurse, working alongside the visiting respiratory educator.

Further information can be found at the following links:

• Case study
• Model of care

Dr Chandrans Surgery (Albion Park) developed a nurse-led respiratory disease management clinic to manage the increase in patients presenting with exacerbation of COPD and asthma during winter.

The practice reviewed their current systems, upskilled their practice nurse in spirometry and established new workflows.

Further information can be found at the following links:

• Case study
• Model of care

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.

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.

Working together, the nurse and GP developed a structured template for diabetes review, then ran a series of consultations with a target group of patients with high-risk diabetes mellitus type 2.

Further information can be found at the following links:

• Case study
• Video
• Model of care

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.

Further information can be found at the following links:

• Case study
• Video
• Model of care

Parkes Street General Practice was one of four medical practices in the Illawarra region who took part in the program to help their patients learn about and plan for the end of life they hoped for.

Doctors and nurses at Parkes Street General Practice, Helensburgh, completed online training in advanced care planning before addressing the sensitive topic with patients.

Further information can be found at the following link:

• Case study

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 hospitalisations and generally poorer quality of life. This project targeted these patients. 

Further information can be found at the following link:

• Model of care

In June 2021, COORDINARE funded five mainstream general practices to help them form partnerships with Aboriginal and Torres Strait Islander people. 

Practices used an experience based co-design approach to support them to be culturally sensitive, responsive, and facilitate better access to primary care for all Aboriginal people.

Further information can be found at the following link:

• Case study

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.

COORDINARE funding supported Worrigee Street Medical Centre in Nowra to work in partnership with the Illawarra Shoalhaven LHD, to implement a quality improvement activity through Kidney Health Australia.

Practice-led quality improvement activities aimed at better detection and management of chronic kidney disease are an important means of improving kidney health in the region.

Further information can be found at the following link:

• Case study

Russell Vale Family Medical and Acupuncture Practice 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 the continuity of care through better engagement and understanding of the patient.

Further information can be found at the following links:

• Case study
• Model of care

Practices have an important role to play in facilitating and co-designing programs within primary care that aim to reduce the burden of chronic conditions in our region.

The Shared Medical Appointments initiative represents a new model of care for the prevention and management of chronic conditions in general practice.

Further information can be found at this link:

• Case study