Nurse-Led Clinics in Action: Meeting Community Needs in Tumbarumba

Roths Corner Medical Centre in Tumbarumba has demonstrated that nurse-led clinics can be successfully implemented in any community when they're designed to meet local needs and make the most of existing general practice capabilities.

Recognising a gap in chronic respiratory care, the practice established a Chronic Respiratory Management Nurse-Led Clinic with a focus on patients living with COPD, many of whom are at high risk of hospitalisation. The clinic provided a structured and supportive environment where patients received targeted education and person-centred care to empower them in managing their condition.

Key outcomes from the clinic include:

• 12 Nurse-Led Clinics delivered

• 15 patients seen over 4 dedicated sessions each, focusing on comprehensive care and health coaching

• 100% of patients rebooked for ongoing care

• 100% were referred for relevant specialist or allied health follow-up

• Average time per patient: approximately 133 minutes, allowing for in-depth support and education

Practice Manager and Practice Nurse, Shae, shared that the project significantly benefited their rural community. Patients became more engaged in their health journey, built stronger relationships with their care team, and appreciated the opportunity to ask questions and feel genuinely heard.

“Participating in initiatives like the Summer Strategy gave our team the space and support to prioritise chronic disease management, from care planning and health assessments to ensuring timely allied health referrals,” said Shae. “It also meant we could rebook patients for their next visit before they walked out the door, making sure nothing fell through the cracks.”

This case demonstrates that when nurse-led clinics are tailored to the unique needs of a town and embedded within the day-to-day operations of a general practice, they can lead to meaningful improvements in patient care, continuity, and outcomes, no matter the size or location of the community.

Healthy Ageing at TMC Medical: A Nurse-Led Approach

When TMC Medical looked closely at the care needs of their patients living in local Residential Aged Care Facilities (RACFs), a problem became clear: residents were missing out on timely, holistic care. General Practitioners simply didn’t have the hours to provide the long, complex consultations required.

To change this, the practice introduced an innovative Nurse-Led Clinic Model, piloted through the Living Well, Your Way Summer Strategy. The idea was simple but powerful to give nurses the lead in aged care consultations to ensure residents received thorough, personalised attention and care while easing the burden on GPs.

At the heart of this model was Lead Nurse Lauren Carter, whose passion for aged care brought both skill and heart to the clinics. “It’s personal for me,” Lauren explained. “So many of our residents are lonely, and the clinics made a difference, especially for those without family. It made the care feel personal rather than clinical.”

Over three clinics, Lauren saw 15 residents, spending an average of 43 minutes with each patient. They were booked for follow-up appointments, and 10 residents were also onboarded to the HOPE digital platform to track their quality of life and the interventions implemented in the clinics.

For the GPs, the benefits were immediate. Dr Alireza Yousefi described the change: “It supported my time management to know health assessments were being done in the RACF where usually they would be delayed. It takes a load off a very busy schedule, while still trusting the work is being done.”

Behind the scenes, the model also streamlined practice workflows. Practice Manager Tahli Hattwell reflected, “The team complement each other and work well together to support our patients. Lauren picked up extra days to run the clinics, and it only positively impacted how we managed the needs of our residents.”

For Lauren, leading the clinics was not just about providing care, but also about professional growth. She spoke of the autonomy the model allowed her, and how working within an aged care home required adaptability and resilience.

The success of the pilot has inspired TMC Medical to think bigger. With strong support from RACF partners, they now plan to evolve the model into a multidisciplinary team approach, bringing in dietitians, exercise physiologists, and other allied health professionals to work alongside the lead nurse.

The vision is clear: to provide aged care residents with a holistic, team-based model of care that meets not just their medical needs, but also their physical, social, and emotional wellbeing.

Closing the Gap in Harden: Nurse-Led Clinics Supporting First Nations Health

Living Well Your Way rolled out a Summer Strategy program to General Practice across the Murrumbidgee. Kruger Medical Centre in Harden participated delivering nurse-led clinics designed around the specific needs of the local community, to deliver culturally safe, accessible, and impactful care, for First Nations peoples.

After reviewing both MPHN Health Needs Assessment data and their practice records, the team at Kruger identified a clear priority: to better support First Nations patients in the areas of preventative health and chronic disease management. With a large First Nations population living in Harden and the surrounding region, the clinic developed a First Nations Nurse-Led Clinic focused on building relationships, trust, and continuity of care.

Led by highly experienced practice nurse Rosemary, the clinic model encouraged and booked whole-family appointments, ensured cultural safety throughout her appointment by creating a welcoming environment where community members felt safe and supported.

Key outcomes included:

• 10 Nurse-Led Clinics delivered

• 15 First Nations patients engaged in care

• 100% of patients rebooked for follow-up

• 73% referred to relevant specialist or allied health services

• Average time spent per patient: approximately 53 minutes

Despite facing challenges, including a natural disaster that affected the town during the project, Rosemary and the team remained steadfast in their commitment, continuing to deliver care and maintain trust with their community.

Kruger Medical Centre achieved an 80% attendance rate, and what stood out even more was the growing number of self-referrals. Word quickly spread throughout the community, driven by the genuine care and enthusiasm of lead nurse Rosemary, whose passion for the work created a ripple effect. Her positive, can-do attitude was felt by patients and staff alike, proving that when you truly believe in what you're doing, it resonates with others and drives meaningful engagement.

The Kruger team’s determination and culturally responsive approach played a key role in supporting early intervention, prevention, and ongoing chronic disease care, making real progress toward Closing the Gap in health outcomes for First Nations people.

By embedding respect, time, and continuity into their nurse-led model, the team at Kruger Medical Centre demonstrated what’s possible when healthcare is community-informed and locally led.

Nurse-Led clinics featured in The Hive

Congratulations to Elise and Danni! The Living Well, Your Way team have had some of their innovative nurse-led projects mentioned in the Australian College of Nursing's 'The Hive' magazine, following on from their outstanding presentations at the National Nursing Forum in Canberra earlier this year.

A fantastic recognition of their expertise, innovation, and contribution to strengthening primary health care in our region.

Read The Hive here: https://publications.acn.edu.au/hive-nnf2025

MPHN showcases regional innovation at national nursing festival

Members of the Murrumbidgee Primary Health Network team proudly represented our region at the 2025 APNA Festival of Nursing in Brisbane, an international celebration hosted by the Australian Primary Health Care Nurses Association (APNA), the peak body for nurses working in primary health care.

Practice Nurse Program Officer Elise Penton and Change Manager Danniell Taylor from the Living Well, Your Way team took to the stage to share how collaborative commissioning is reducing hospitalisations and improving health outcomes across the Murrumbidgee. Their presentation highlighted the impact of local, community-based solutions and the strength of partnerships across the region.

Elise also co-presented with Practice Manager and Transitional Nurse Practitioner Rebecca Manski from Tumut Family Medical Centre on the growing role of nurse-led clinics in rural communities. Their session explored how these clinics are empowering nurses to lead care delivery, improve access, and support stronger health outcomes in areas that need it most.

We’re incredibly proud of our team for representing MPHN on a national platform and for showcasing the power of regional innovation in primary health care.

From left, Clinical Programs and Emergency Response Manager Peta Anderson, Practice Nurse Program Officer Elise Penton, Practice Manager and Transitional Nurse Practitioner Rebecca Manski, and Change Manager Danniell Taylor.

Pharmaceutical Society of Australia Conference 2025

Recently, Living Well, Your Way Community Pharmacist Kym Ramsey presented at the PSA25 conference in Sydney, representing the LWYW team and program pharmacists.

Delegates and stakeholders showed strong interest in the program, with Kym’s presentation “Utilising rural community pharmacists to screen for chronic diseases” recognised as the PSA/APSA Best Oral Presentation at the conference.

Congratulations to everyone involved in the program, including pharmacists, pharmacy staff, screened patients, and general practices.

Images: A/P Lisa Kalisch Ellett, President APSA; Kym Ramsey, Living Well, Your Way Community Pharmacist; A/P Dr Fei Sim National President PSA.

Virtual Hospital in the Home

​​​​​​Wagga and surrounds 

Virtual Hospital in the Home is available for patients with acute or subacute respiratory illness, residing within 40km of Wagga, who require daily nurse review but can otherwise manage at home.

Referrals from a GP to include: 

• Patient details including contact details

• Clinical summary

• Current medication list

• Recent relevant special investigation result (pathology/imaging).

For more information and referral, please contact RAC Medical Officer during hours of operation.
Email after hours with ATTN: Respiratory HiTH Nurse MLHD-Wagga-HITH@health.nsw.gov.au

Griffith

Griffith is set to expand its model of care in July to include a virtual service for patients with acute or subacute respiratory illness or at high risk for severe disease. Referral information to come.

Griffith Base Hospital Outpatient Clinics

Respiratory Public Outpatient Clinic: 

The Griffith Respiratory Public Outpatient Clinic has held 15 clinics over the last 12 months with a further ten clinics scheduled to the end of 2025 supporting respiratory patients with complexities, comorbidities, frequent ED presentations or admissions to hospital. Access to this service is by directly referring GPs, hospital medical officers and visiting medical physicians.

Patients have reported very positive experiences with how our health professionals explain things in a way they understand and provide clear explanation of the next steps they need to take following their appointment.

Heart Failure Public Outpatient Clinic:

In May 2025, Griffith Base Hospital trialled their first Heart Failure Public Outpatient Clinic. The clinic's focus is to support people who have frequently presented to Griffith Base Hospital ED or been admitted with complexities with heart failure, with a goal to keep these people healthier at home for longer and to reduce presentations to hospital over our winter period. At this early trial stage, referrals are from Griffith Base Hospital only. 

Outreach Respiratory Clinics

This year, we are trialling an expansion of the successful Outreach Heart Failure Diagnostic Clinics, into Outreach Respiratory Clinics across the Murrumbidgee Local Health District.

These clinics are designed to support patients who have been diagnosed with, or are at risk of developing, respiratory conditions. The focus is on individuals with complex medical needs, multiple comorbidities, and/or those who experience frequent hospital admissions due to respiratory illness.

The Outreach model aims to improve access to specialist respiratory care in rural and remote communities, ensuring early intervention, coordinated care, and reduced hospital burden through comprehensive, locally delivered services.

So far, six regional clinics have already been conducted, treating over 40 rural and remote patients closer to home. Planning for additional outreach respiratory clinics is underway and we look forward to bringing the dream of equitable healthcare in rural locations that much closer.

For more information about the program and referrals please contact info@livingwell.org.au.

Winter Strategy 2025 - July 2025 Update

General practices from across the Murrumbidgee region have commenced participating in this year's Living Well, Your Way Winter Strategy program. This year, 36 practices are participating, the biggest cohort in its seven-year history.

Winter Strategy enables practices to support up to 900 chronic disease patients, providing much needed clinical interventions, care and education to assist with proactively managing symptoms, to keep them well over winter.

This year’s program has introduced in-practice commencement workshops, monthly online 'lunch and learn' webinars, symposium education days, and introduced the Basecamp platform, allowing access to resources and interaction with the support team and other practices.

This year, research is being conducted to evaluate the impact of Winter Strategy on hospital usage. Participating practices have commenced patient recruitment and pre-surveys. The outcome of the evaluation will offer vital insight into improving service delivery in the future. A report will be available at the end of this year.

To access education and to find out more about the Living Well, Your Way Winter Strategy Program, please visit our website.

Pharmacy Screening Program – July 2025 Update

The Living Well, Your Way Pharmacy Screening Program has been extended until 30 September 2025 with 24 pharmacies continuing to screen patients. Patients identified as at risk of COPD or CHF are referred to their GP for further assessment.

20 program pharmacies have also taken the opportunity to provide in-pharmacy education to patients already diagnosed with COPD or CHF utilising funding from Living Well, Your Way and through the MedsCheck program.

Living Well, Your Way Community Pharmacist, Kym Ramsey is currently travelling to program pharmacies to educate and support them in both patient screening and education.
 
Participating pharmacists have reported overwhelmingly positive feedback, highlighting the benefits of screening and spending more time with patients to support early intervention and better health outcomes.

Living Well, Your Way have engaged the services of Human Capital Alliance to evaluate the program, with results due in October 2025.

Up till end of June 2025, a total 292 patients have been screened with 138 referrals sent to their doctor for further assessment.

To find out more about what the program involves or to find a participating pharmacy for a FREE Screening click here.

Nurse-Led Clinics: A Summer Strategy Success for Murrumbidgee

The Living Well, Your Way Summer Strategy is a Murrumbidgee Primary Health Network led initiative, held between October and May 2024-25. The initiative successfully introduced a new model of care, nurse-led clinics, at 17 general practices across the region. The aim was to support prevention, early intervention, and long-term chronic disease management by empowering nurses to work to their full scope of practice, delivering innovative, patient-focused, care closer to home.

This initiative provided general practices with funding to support the design and establishment of a sustainable nurse-led clinic model in their practice. 262 patients participated in 106 clinics across five key clinical priority areas: healthy ageing, First Nations health, chronic respiratory disease, chronic heart failure, and diabetes management.

Key outcomes of initiative include:

• An increase in nurse confidence and clinical leadership through hands-on clinic management and decision-making roles.

• Improved patient engagement and satisfaction by offering timely, accessible care tailored to individual needs.

• Stronger collaboration and teamwork between GPs, nurses, and administrative staff, enhancing continuity of care.

• Identification of sustainable pathways, protocols, and tools to support the expansion and ongoing success of Nurse-Led Clinics across the region.

Spotlight Feature: Boorowa Street Medical Practice, Young

Boorowa Street Medical Practice has been a standout participant, launching a dedicated diabetic nurse-led clinic with a focus on foot health, a critical component of diabetes management. Over four months, the team delivered 11 targeted clinic sessions, providing ongoing assessment and education to 17 patients. Led by practice nurses Roxanne and Sue, this clinic has successfully met the specific needs of the local community through structured, evidence-based care.

Building on this momentum, Roxanne has further expanded her clinical expertise by establishing a respiratory clinic aimed at patients living with COPD and asthma. This service now offers spirometry testing, diagnostic support, and targeted interventions designed to reduce hospital admissions and improve quality of life for patients in Young and surrounding areas.

Roxanne reflects on the journey with enthusiasm: “I found these clinics really beneficial and encourage anyone thinking about starting one to just get in and give it a go.” Her words echo the positive impact nurse-led models can have, both for patients and for the professional development of nurses themselves within the Murrumbidgee district.

For more information about Summer Strategy and nurse-led clinics email:
info@livingwellyourway.com.au

Celebrating the Heart of Our Community: Temora Medical Complex Nurses Lead the Way in Healthy Ageing

From left to right; Libby, Gillian and Lucy.

In a heartwarming display of community spirit and innovation, the nurses from the Temora Medical Complex have been doing something extraordinary for the elderly residents of their town. Temora Medical Complex are one of 18 general practices across the region who have signed up to participate in Living Well, Your Way: Summer Strategy supporting the establishment of sustainable Nurse Led Clinics. The focus of their Nurse-Led Clinic project is Healthy Ageing.

Recently they set up a lively and engaging stall at the local Healthy Ageing Expo, showcasing their exciting new initiative—the "Good Old Days" Healthy Ageing Clinic.

This new clinic is all about keeping elderly community members healthy, happy, and most importantly, at home for longer. The nurses have taken the lead in crafting personalised, practical healthcare solutions that allow the elderly to maintain their independence and quality of life. From managing chronic conditions to providing valuable health advice, the clinic is tailored to meet the unique needs of older adults, helping them age with dignity and grace right in the comfort of their own homes.

At the Healthy Ageing Expo, the nurses went above and beyond to promote this wonderful initiative, offering helpful information and creating connections in their community. Their enthusiasm was infectious, and the community response was overwhelming. People gathered at their stall to learn more about how the "Good Old Days" clinic can make a difference in the lives of seniors in Temora.

It’s not just about health checks and medical support; it's about building connections. The nurses have created a space where elderly people can feel heard and cared for. It's this sense of community and personal attention that sets the clinic apart, making it a much-needed resource for families who want to ensure their loved ones live their golden years to the fullest.

In a town where kindness and connection are at the heart of everything, the Temora Medical Complex nurses are leading the charge in redefining what it means to age well. So, here’s to the amazing nurses at the Temora Medical Complex - thank you for going above and beyond to keep our community strong, healthy, and connected for many more good old days to come!

To find out more about LWYW Summer Strategy: Nurse Led Clinics visit www.livingwellyourway.org.au or contact info@livingwellyourway.com.au.

Patient Story: Denise

Denise, a 60-year-old woman was recently transferred to Wagga Base Hospital after presenting to ED at the Tumbarumba Hospital.    

Denise is a life-long smoker with known emphysema and COPD and presented to ED with sharp central chest pain and suspected peri-myocarditis caused by an infection. Upon initial bedside transthoracic echocardiogram, moderate LV dysfunction was found. Formal TTE revealed an EF of approx. 40-45% with mild to moderate LV dysfunction and was started on heart failure medications including Bicor, Entresto and Spironolactone. She was discharged with a plan to follow up at the Heart Failure Clinic for a repeat ECHO and review.   

Upon attending the Heart Failure Clinic, Denise showed significant improvements in her symptoms and a normalisation of her ejection fraction.   

Denise described her experience of the clinic as extremely efficient. She was very happy with the service and said everything was explained to her and she was given a clear plan, moving forward.   

She commented that having access to these services at no cost was important as she didn’t know what she would do if this clinic wasn’t available. Denise had visited a Respiratory Specialist some years ago but did not return for the follow up appointment due to the associated costs and mentioned she is unlikely to attend her follow up appointment with the Cardiac Specialist for the same reason.   

Living alone and in the Tumbarumba region, travel to Wagga can be difficult and cost associated with visiting a specialist is better spent on firewood to heat her home. Denise is very grateful for the opportunity to be included in the clinic and hopes they can continue to run and assist people like herself.   

Denise is now being managed by her GP back home in Tumbarumba and has been referred to the Outpatient Respiratory Clinic by the HF CNC for management of her COPD.   

Patient Story: Michael

Michael has completed Pulmonary Rehab at Temora Hospital. He was a regular attendee of the group, travelling near 40km from Ariah Park to participate and help better manage his COPD.

Initially, Michael identified that even walking to the end of the street was effortful and was faced with having to retire from work due to struggles with environmental dust and shortness of breath.

Throughout pulmonary rehab, Michael was linked in with the respiratory nursing staff and provided with education on how to better manage his inhalers, and independently sourced a COPD Action plan with his GP.

Michael recently completed his final outcome measures, where he made large improvements on his 6 minute walk test, CAT and EQ-5D-5L.

Michael has since been empowered to assist others in the community struggling with lung conditions and motivation. As a result, he has created a walking group at Ariah Park where up to 8 members of the community attend and walk up to 5km once a week. He reports even educating people about the BORG scale and how it helps to pace yourself when struggling with breathlessness.

Due to the popularity of the group, Michael is now in the process of starting up a second group! Go Michael!!

2024 Year in Review

Read our Year in Review to find out the highlights of the program to date.

Medical Director GP Heart Failure Prompt

In early 2024, Living Well, Your Way successfully trialled an automated software prompt with Telstra Health to identify patients at risk of COPD.

This prompt will continue over the next three months, with a focus on people at risk of heart failure.

The aim of the prompt is to assist GPs to identify patients who are taking medications prescribed for heart failure, yet without a formal diagnosis on file.

The trial aligns with the introduction of MBS item number 66829 for NT-proBNB and BNB testing to help with diagnosis of heart failure in primary care.

The prompt also promotes the new heart failure services available across the Murrumbidgee through the Chronic Respiratory and Heart Failure Service at MLHD.

To find out more about these Pathways and referrals please click here for information via Health Pathways: New Onset Heart Failure - Community HealthPathways Murrumbidgee.

For enquiries or feedback on the prompt, please contact info@livingwellyourway.org.au

New Virtual Respiratory Hospital in the Home (HITH) available for patients in Wagga Wagga

Do you have a patient with acute or subacute respiratory illness who requires daily medical review but can otherwise manage at home?

The Virtual Respiratory Hospital in the Home (HITH) provides General Practitioners an alternative management pathway for patients with acute or subacute respiratory illness who may benefit from daily medical review and management within their home.

Based on GP referral, HITH provides Virtual Consultations with patients including home Risk Assessments, Education & Self-Assessment tools.

Daily reviews with patients can be virtual or face to face allowing for: observations, monitoring of symptoms, pathology/sputum collection, comprehensive patient centred care, and escalation of care as required.

Upon discharge, HITH provides the GP with a discharge plan including scripts/medical certificates. Patients are encouraged to book a follow up appointment with their GP.

For advice and referral contact: Virtual Respiratory HiTH Nurse 0459 807 637 Email: MLHD-Wagga-HITH@health.nsw.gov.au

Download flyer

Patient story

During a recent admission to the virtual HITH service, Michelle* a 51-year-old female with known COPD, Emphysema and Asthma received a management plan and was educated on how to take her own observations. She received daily virtual assessments by a respiratory nurse.

Michelle* described her experience of the Virtual HITH service as much better than staying in hospital. The nurse stayed connected everyday with a video link or a phone call, and Michelle* felt she ‘most certainly’ received the same level of care as she would in hospital.

Following her discharge from VHiTH, she attended the public Respiratory Clinic in Wagga. Michelle* said she now feels more confident to stay at home and manage her condition – she can identify when she is feeling unwell and knows when to act and is even thinking about trying to quit smoking.

* Name changed.

World COPD Day 2024

Chronic Obstructive Pulmonary Disease (COPD) affects 1 in 13 Australians aged 40 and over, yet half of them don’t know they have it. Alarmingly, Indigenous Australians are 2.5 times more likely to have COPD.

This World COPD Day, we’re joining Lung Foundation Australia in sharing key resources for best-practice COPD care with patients and healthcare providers.

In October 2024, the Australian Commission on Safety and Quality in Health Care published Australia’s first national COPD standard to guide best practice care. But what does it mean for your clinical practice?

Delivering best-practice care is made easy with the COPD-X Handbook, the point-of-care resource specifically designed for healthcare professionals in primary care.

Read now

For more information and to access resources and support services for you and your patients, visit lungfoundation.com.au. 

Clinician education

This World COPD Day on Wednesday 20 November, Lung Foundation Australia are diving into the latest clinical and system-level updates for national best-practice COPD care with a virtual learning event titled 'COPD: How does your practice measure up?'

Join the expert panel, Dr Kerry Hancock and Dr Lee Fong with host Mary Roberts, to unpack the new COPD Clinical Care Standard and receive practical tips for implementation in primary care using the COPD-X Handbook. 

This virtual learning is Lung Learning quality assured and CPD accredited for 1 Educational Activity hour with RACGP. 

Date: 20 November 2024  
Duration: 1 hour 
Time: 6:00pm

Register now

General Practice Spotlight – Vecare Health: Holbrook

Vecare Health has truly made its mark in the vibrant communities of Holbrook and Walla Walla, earning a reputation for outstanding primary care over the years. Joining Winter Strategy for a second consecutive year, Vecare are once again pulling out all stops to deliver the program aiming to make a difference for their patients and the wider community.

Their innovative “Winter Wellness Program” has become a local favourite, particularly for patients managing chronic obstructive pulmonary disease and chronic heart failure. The buzz around their Winter Wellness Program is palpable.  

"We had patients from both Holbrook and Walla Walla asking when the Winter Wellness Program was going to start months before winter even began!” shares practice manager, Mr Harneet Gill.

What is the secret behind their success? A dedicated and cohesive practice team putting their patient’s wellbeing and needs at the centre of care. Practice nurses, Lauren and Miranda, are at the heart of this initiative, providing exceptional patient-centred care through personalised care planning and goal setting. Their commitment to keeping patients well and out of the hospital shines through.  

“Our patients, especially those most vulnerable during winter, have really benefited from these regular connections with their general practitioner and nurses,” Lauren explains. “The program has been a fantastic success; patients love the additional check-ins and the extra time we spend together. They genuinely feel cared for.”

Harneet, Lauren, Miranda and their team of general practitioners are highly committed to supporting their rural communities during the winter months. They cherish being part of the Winter Strategy each year, seeing it as a chance to make a meaningful difference in their patients' lives. The Winter Wellness Program (Winter Strategy) has now become an integral and eagerly anticipated part of their annual care routine.

Image left to right: Samantha - Medical Receptionist, Lauren Hand – Registered Practice Nurse, Suhda Jayaraman - General Practitioner and Harneet Gill - Practice Manager