Progress updates: August 2022

The Living Well initiative is currently in the Implementation Phase of the initiative.

Recent milestones include:

✓ Clinical Advisory Group established

✓ Costing of new care pathway alongside IQVIA

✓ Approval of the new Living Well, Your Way Care Pathway

✓ Refresh of the Pulmonary Rehabilitation Service (now called Restoring Function).

Ongoing work includes:

  • Developing multidisciplinary Respiratory Outpatient Clinic

  • Establishing pharmacy linkages – patient-provider-pharmacy pathways and possible models for referral and support

  • Developing Hospital in the Home (HITH) pathway

  • Rolling out Living Well, Your Way General Practice Winter Strategy

  • Rolling out Lumos – a new program for sharing data across the NSW health system.

Introducing the Living Well Care Pathway

Following consultation with more than 200 stakeholders in our region, the Patient Centred Co-Commissioning Group (PCCG or the Joint Executive Governance Group) has approved the Living Well, Your Way Care Pathway. Each stage brings together a range of healthcare professionals to support people living with COPD and CHF to navigate their health journey.

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Our plan

Our plan is to make small and large-scale changes to the way care is delivered, informed by data, and led by people with lived experience of chronic conditions as well as their health care professionals.

  1. Pre-Development Phase – This phase began in 2020 with the formation of a collaborative commissioning group and securing funding. In line with our funding agreement, we have three years from the start of the funded initiative to prove this model is sustainable. And we have every intention of getting this right and continuing well beyond the first three years!

  2. Joint Development Phase (Design and Costing) – This phase began in July 2021 and included consultation with clinicians, MLHD and MPHN executives and teams, GP practices, pharmacies and other stakeholders, including patients and carers. In this phase we are clarifying who will participate in the initiative (our cohorts) and how they qualify to be part of the initiative (criteria), designing and mapping the care pathway including costings and working up a summary of benefits.

  3. Feasibility Phase – The feasibility phase saw us put in place the models of care developed during consultation and assess their effectiveness and sustainability. The plan is to start small – trial changes in certain communities, review and expand over time.

  4. Implementation Phase – In 2022 we entered the full implementation phase, where we are rolling out the most effective models of care and closely monitoring the outcomes.