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

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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

Winter Strategy 2024 Update

Winter Strategy 2024 is progressing well this winter with general practices engaging with new and existing patients to providing proactive care and interventions to help reduce hospitalisations over the colder months.

Patients

We are expecting to have about 750 patients participating in the program for 2024. Practices are focusing on providing timely immunisations, monitoring patient symptoms with check ins and using CareMonitor, conducting spirometry and ECGs, updating Sick Day Action Plans (SDAP) and GP Management Plans (GPMP), plus much more.

Heart Plan in a Box has been successfully introduced into this year’s Winter Strategy with 18 practices undertaking quality improvement activity for heart failure management and care within their practices. Heart Plan in a Box provides a hands-on toolkit with exceptional evidence-based resources designed to improve heart failure patient management from experts across the nation.

Education

Spirometry training was delivered across five locations during May with 51 clinicians attending. We are currently completing the assessment of all attendees. We will be considering more spirometry training prior to the next Winter Strategy in 2025. Training is open to all practices and clinical staff. If you are interested please email info@livingwellyourway.org.au.

A huge thank you to Robyn Paton, MLHD Respiratory Clinical Nurse Consultant for her dedication to deliver education to practice nurses and GPs throughout the Murrumbidgee over the past few years. We welcome Sistine Anne Ramajo-Aredidon who is currently acting in the role.

As part of the Winter Strategy education plan, 13 education sessions have been delivered with 113 general practice staff attending. 

Keep an eye out for upcoming sessions including:

• Transforming Tomorrow: How to Launch and Lead Sustainable Nurse-Led Clinics

• Coaching for Change: Essential Conversations for GPs on Changing Behaviours and Advanced Care Planning (Face2Face event hosted in Wagga Wagga).

• Breaking the Stigma of Advance Care Planning (Face2Face event hosted in Young)

All delivered sessions have been recorded and can be accessed at here. A specific password to access the education section is required – please email info@livingwellyourway.org.au for a password.

Recorded sessions available are:

• COPD 101 Best practice for diagnosing, assessing, and managing your patients with COPD)

• Leading QI

• Triage for non-clinical staff 

• Optimising MBS Billing – Maximising revenue with MBS Item Numbers

• Heart Plan in a Box + CHF 101

• Sick Day Action Plans: Educating your Patient

• Discover the 715: Enhancing Cultural Health Assessments

In-service

New on offer is education with Elise Penton our Practice Nurse Project Officer, and our Clinical Nurse Consultants in respiratory and heart failure from the MLHD who are now available to come to your practice to facilitate hands-on learning. If you are interested in hosting an in-service for your staff, please reach out to Elise to arrange a time at elise.penton@mphn.org.au.

Images: Spirometry at Griffith June 2024 led by Robyn Paton MLHD

Marathon Health Pulmonary and Chronic Cardiac Exercise and Education Program

Marathon Health in partnership with Back on Track Physiotherapy are offering a free 8-week Pulmonary and Chronic Cardiac Rehabilitation (PCCR) program designed to support an improved quality of life for people living with a chronic respiratory condition or CHF and reduce their likelihood of associated hospital admissions.

The program offers patient-centred therapy with a focus on small group exercise and education sessions, with other services sometimes available on a case-by-case basis. 

Do you have an eligible patient?
People who are living with a chronic respiratory condition or CHF.
Located within travelling distance to the centre where the program is delivered.

How do I refer?
Please complete the referral form and email to pccr@marathonhealth.com.au 
If you need help with the referral, please call 1300 418 223

Program dates
Junee – July to September 2024
Leeton – October to November 2024
Lake Cargelligo – February to March 2025
Hay – April to May 2025

Pharmaceutical Society of Australia Conference

Recently at the PSA24 conference in Sydney, our LWYW Community Pharmacist, Kym Ramsey represented the Living Well, Your Way team and pilot pharmacists, delivering a poster presentation at the conference.

Pharmacists at the conference gave positive feedback, including asking how they could be involved. Of the 44 poster presentations, the Living Well, Your Way Pharmacy Screening Pilot Program was voted as the best. Congratulations to all involved in co-designing and delivering the pilot.

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

Innovation in Primary Care Program

22 General Practices from across the region have been successful in participating in the Innovation in Primary Care program. 

The aim of the initiative is to assist general practices in trialling two new technologies to support holistic care for patients with chronic disease. 

• 20 General Practices are using Care Monitor platform to support patients to self-monitor and record their COPD and Heart Failure symptoms from home, using a mobile app. The program commenced in 2023 with participating practice installing software and onboarding patients into using the app. Proudly we now have active participants using Caremonitor with some exciting and positive health outcomes achieved within our local communities. 

• 2 General Practices have commenced using the NSW Health Outcome and Patient Experience (HOPE) platform to collect patient reported measures (PRMs) data, using online surveys. 

As part of the initiative, participating practices have been supported to build these technologies into their workflow with the intention of providing care more efficiently and empowering patients to take a hands-on approach managing their chronic disease. 

For more information please contact Kelly Dal Broi, LWYW Senior Project Officer on 0488 004 970 or E: info@livingwellyourway.org.au

Outreach Heart Failure Diagnostic Clinics

The Outreach Heart Failure Diagnostic Clinic supported by A/Prof Andrew Roy from the St Vincent’s Network, funded using COAG 19 (2) Exemptions, aims to ensure patients in rural communities at risk, or have symptoms of heart failure have timely and affordable access to screening and diagnostic assessment including echocardiography.

Our most recent clinics have been held in West Wyalong at Kure Medical in September, and then in Hay at Hay medical Centre and the Hay Aboriginal Medical Service. Across these clinics we have seen a further 28 patients.

There were numerous new heart failure diagnosis and new clinical findings clinic investigations, with 9 clients likely avoiding ED presentation/hospital admission/ clinical events. Where identified, clients were linked with community services to ensure a holistic approach to care.

Clinician supported telehealth consultations has been effectively utilised within the clinics with positive feedback from all clients involved.

Feedback from both the host practice, patients and their families has been extremely positive, appreciative of no cost, with clear, comprehensive information and education provided.

The Outreach team passes on their gratitude to the host practices, Kure Medical, Hay Medical Centre and Hay Aboriginal Medical Service, to all the referring General Practitioners, Nurse Practitioners and efforts of the practice nurses and managers, from West Wyalong, Temora and Hay, and without this, the clinics wouldn’t be possible.

We look forward to our next clinic scheduled in Lake Cargelligo on the 14th and 15th November and are now accepting referrals.

For further information contact mlhd-respiratoryandheartfailureclinics@health.nsw.gov.au