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 2024

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