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.

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.