OUR PATHWAY

The Living Well, Your Way Pathway

Click on the magnifiers to see our partners and partnerships along The Pathway.

Objectives of the Pathway

The goal of the Pathway is to keep people with COPD and/or CHF healthier at home for longer. The targeted outcomes include:

•      Improved quality of life for people with COPD and CHF.

•      Reduced demand for hospital services for people with COPD and CHF.

•      Reduced avoidable mortality for people with COPD and CHF Overview of the Pathway.

 Key principles underpinning the Pathway:

•      Consumers should always be in the community unless it is clinically unsafe to do so.

•      Each point of service is to ensure the consumer is linked to the next appropriate service so there is continuity through the Pathway.

•      An individual may enter the Pathway at any stage, however, the primary goal is for the individual to return to and remain in ‘optimal care in the community’.

•      The long-term aim is for every consumer to have one Health and Wellbeing Plan, which integrates existing action plans and care plans, and is ‘translated’ into non-clinical language and connected to the consumer’s personal circumstances.

The Pathway is comprised of seven key focus areas (stages) which encompass the whole of health care system in the Murrumbidgee region.

Prevention, Screening & Intervention

  • Early screening and targeting health messaging for COPD and CHF in pharmacies and general practice.

  • Formal links between GPs, pharmacies and community groups to provide interventions for people at risk.

  • Streamlining care planning and information sharing to achieve greater outcomes.

Early Diagnosis

  • Increased access to affordable diagnostic testing in community and outpatient settings.

  • Specialist outreach clinics for high risk priority populations

  • GP support models to enhance timely and accurate diagnosis.

Proactive Treatment

  • Expansion of hospital avoidance strategies such as the Rapid Access Clinic (RAC) in Wagga and Hospital in the Home (HITH) Programs in Griffith and Wagga.

  • Realignment of existing LHD clinical service providers to provide outreach care for subacute patients with chronic disease, with virtual clinical support models.

Transition to Home

  • Implement hospital in-reach for community-based services using a direct referral ‘opt-out’ system.

  • Routine home or telehealth visit on discharge from hospital including social worker support where required.

  • Public specialist outreach clinic for patients post-discharge.

Restoring Function

  • Access to a standard hybrid model of cardiorespiratory rehabilitation across the region – regardless of location.

  • Links to step down community exercise groups following rehabilitation.

Optimal Care in the Community

  • Contractual engagement with GP practices ad pharmacies to provide wholistic care in the community in return for business and clinical capacity building

  • Enhanced team-based approach to care in the community through clinical and service pathways.

  • Outcome-based performance criteria central to commissioned service agreements (inc allied health) with innovative workforce models to promote optimal care in the community.

  • Supported transition to palliative care promoting holistic care.