Collaborative Commissioning
Origin & development
The Murrumbidgee Primary Health Network (MPHN) and Murrumbidgee Local Health District (MLHD) Collaborative Commissioning partnership was formed to develop and implement a care pathway for people living with Chronic Obstructive Pulmonary Disease (COPD) and/or Congestive Heart Failure (CHF). In 2019, the Patient Centred Co-Commissioning Governance (PCCG) group was established to oversee the development of the Living Well, Your Way initiative.
Living Well, Your Way (‘the Pathway’) has been created with the following guiding principles:
No step in the pathway is finished until the next has started.
Clinicians working to the top of their scope.
Collaboration between providers.
Alternatives to the emergency department.
Patient focused; Data driven.
Pathway Co-design
In 2019 co-design of LWYW began with significant consultation of a wide range of stakeholders from across the region. Virtual co-design events with 12 workshops were held over three days in October 2021, consulting with the equivalent to 200 people (noting that some individuals participated in more than one workshop).
Attendees included representatives from general practice, pharmacy, allied health, health consumers, Aboriginal health staff and community leaders, Ministry of Health, and MLHD and MPHN staff and Executive.
The following program was developed. We are now in Implementation Phase until June 2025. To find out more about our activities click here.
Pre-Development Phase
Aim: Assess the ways people with COPD and CHF receive care and support to manage their condition by asking lots of questions and reviewing lots of data.
This phase began in 2020 with the formation of the Collaborative Commissioning team and securing funding.
Joint Development Phase (Design and Costing)
Aim: Ask how patient health journey can be improved and design a new and better pathway of care.
In July 2021 consultation began with key stakeholders to clarify the target patient cohort and their qualifying criteria. The Collaborative Commissioning Team began mapping the new care pathway including costings and the summary of benefits for this cohort and services. This is where the Pathway was born. To see the full report click here.
Feasibility Phase
Aim: Put the new design to the test to see how well it serves everyone, especially the individuals living with COPD and CHF. Trial and adopt with as many patient volunteers as possible to ensure it is feasible and that the data and patient journey both improve.
The feasibility phase allowed trial of the models of care developed during consultation and assess their effectiveness and sustainability. The trials rolled out across selected communities, reviewed with the intention to expand over time.
Implementation Phase
Aim: Keep going and apply the same pathway to more people and other chronic conditions.
In October 2022 LWYW entered implementation phase with rolling out the most effective models of care. For more information on the Pathway activities please click here.
October 2023 saw the completion of the first year of Implementation.
To see results from our activities please click here.
Where to from here
Implementation Year 2 – Our plans…
Other new models of care will be implemented along the pathway in year two. We are working with Medical Director (Telstra Health) to trial a prompt for patients at risk of COPD in general practice. We have also started work with eleven pharmacies throughout the region to design and deliver a screening program for patients at risk of COPD and heart failure, with the aim of linking patients at risk to their primary care provider for further investigation.
The sustainable delivery of pulmonary and heart failure rehabilitation in our region is a significant challenge. To help improve access, Living Well, Your Way has commissioned a trial of community-based rehabilitation provided by a non-government organisation and local private allied health provider. The Living Well, Your Way team are also partnering with Griffith Aboriginal Medical Services and key stakeholders in the MLHD to design and trial a culturally appropriate rehabilitation program for Aboriginal and Torres Strait Islander participants.
Data monitoring and reporting are vitally important to demonstrate the impact of this pathway. Next year will see the delivery of a reporting dashboard and we look forward to being able to share data aligned to value-based outcomes with you.