Department of Health

Case study 1: integrated health care to a vulnerable population group

This case study demonstrates the development of an integrated approach to the provision of health services to refugees. A framework and tools were trialled with general practice.


People from refugee backgrounds, including those seeking asylum, have complex health and social welfare needs, which are well documented (Russell et al. 2013; Joshi et al. 2013).

Language and cultural differences, limited health system literacy, and socioeconomic disadvantage prevent people from refugee backgrounds accessing primary care services and present challenges to services (Cheng, Drillich and Schattner 2015).

Newly arrived Australian Humanitarian Programme entrants are encouraged to access a Medicare-funded Health assessment for refugees and other humanitarian entrants available for up to one year after settlement.

This assessment is important for early identification and catch up care, and is delivered in community health and by private general practitioners.

Partially due to the low uptake of this assessment, the department-funded Refugee Health Program, based in community health, was established to support increased access to on arrival health assessments for people from refugee backgrounds.

This case study outlines a two-year project by the Victorian Refugee Health Network in partnership with refugee health programs at EACH Social and Community Health and ISIS Primary Care.

This case study details the development and trial of a Framework and Tools for Refugee Health General Practice Engagement using the principles of co-creation with general practice and a range of key stakeholders.

The drivers

General practice is crucial to the provision of on arrival and ongoing healthcare for people from refugee backgrounds, including those seeking asylum.

While there are some general practices in Victoria that have developed significant expertise in refugee health care, there are ongoing challenges in identifying sufficient general practices that are willing, able and confident to work with people from refugee backgrounds.

Initial scoping of this project highlighted that refugee health can be perceived as complex, time-consuming and expensive and that this can act as a barrier to engaging general practice to work with people from refugee backgrounds.

Furthermore, humanitarian settlement will grow and move into new areas and, as new communities are established, general practices will be required in these new regions to provide crucial healthcare.

The players

The Victorian Refugee Health Network and the Victorian Foundation for Survivors of Torture Inc (Foundation House) have a significant history of work to increase the capacity of general practice to respond to the health needs of people from refugee backgrounds.

This includes the development of a number of guides for general practice (Victorian Foundation for Survivors of Torture Inc. 2012), several projects and annual learning forums to increase general practice capacity, including RACGP accredited modules for GPs and practice nurses (Kulkens 2009; Reiner and Webster 2002; Victorian Foundation for Survivors of Torture Inc. 2014).

Much of this work has included partnerships with the Divisions of General Practice, Medicare Locals, Primary Health Networks and other peak bodies such as Networking Health Victoria (formerly General Practice Victoria).

In addition to this, there has been considerable work to engage general practice by many others in the refugee health sector.

This includes the work of state funded refugee health nurses, refugee health fellows, Primary Health Networks and former Medicare Locals.

Practices promoting successful outcomes

The project utilised principles of co-creation to develop a Framework and Tools to support the engagement of general practice clinics to make improvements in their delivery of healthcare to people from refugee backgrounds.

Principles from the literature review about practice facilitation included; general practice engagement requires ongoing relationships, accurate and concise information, and utilisation of a whole of practice approach that considers the mix of practice staff to ensure effectiveness of the intervention (Christl et al. 2010; Pearce et al. 2012).

Complex practice change interventions 'must combine flexibility in the intervention model, implementation strategy, and the evaluation' (Stewart et al. 2010) and must consider the needs, priorities and resources of the practice and the whole of practice team.

This informed the development of the practice engagement tools including a facilitator interview guide; a template for action planning; a template for evaluation and others.

To assist the practice facilitators in developing action plans key components in the delivery of efficient and effective primary healthcare to people from refugee backgrounds was documented and prioritised using the co-creation processes.

This led to the development of the Refugee health framework for continuing improvement. The framework takes a whole of practice approach and outlines foundational skills and systems in key areas of communication, coordination and management; and clinical care.

The tools were trialled with six general practices and modified based on feedback from general practice.

The challenges

The co-creation process of developing the framework and tools had a number of benefits including delivering an approach to engaging practices with varying degrees of experience in refugee health.

Identifying the priority practice skills and systems in refugee health for inclusion in the Framework was contested and therefore time consuming.

Diverse perspectives were represented in the project, and therefore there were challenges in determining not only who should have a voice but also how to balance and privilege their views.

For example, some voices reflected in depth knowledge of the context of general practice, while others reflected significant expertise in working with people from refugee backgrounds.

Bringing such a diverse group of stakeholders together allowed for a rich and deep understanding of a range of perspectives.

The results

The framework ascribes equal weighting to clinical knowledge, coordination and management, and communication.

Engagement with practices demonstrated that practice systems, such as appropriate recall and reminder systems, and processes for the identification of people from refugee backgrounds are priorities.

Use of the tools indicated that early exploration of the values, motivations, and priorities of general practice staff to work with people from refugee backgrounds assisted facilitators to tailor the intervention to the needs of the practice.

This was also a positive approach to relationship building.

While practice staff had considerable good will around improving their practice for people from refugee backgrounds, the commitment to action plans and identification of indicators to measure change was time consuming, required continuity of staff and a long-term relationship between the practice facilitators and general practice staff.

The key learning

The development of the framework and tools, with critical input from general practice, provided an important conceptual anchor point for the practice facilitators to communicate with practices about a specific/specialise area of health care.

For more information

Refugee health framework for continuing improvement and refugee health general practice engagement toolsExternal Link
Telephone: 03 9388 0022


Russell G, Harris M, Cheng I, et al. 2013, Coordinated primary health care for refugees : a best practice framework for Australia: report to the Australian Primary Health Care Research InstituteExternal Link

Joshi C, Russell G, Cheng I-H, et al 2013, 'A narrative synthesis of the impact of primary health care delivery models for refugees in resettlement countries on access, quality and coordination', Int J Equity Health, vol. 12, no. 1, p.88, doi:10.1186/1475-9276-12-88.

Cheng I-H, Drillich A, Schattner P, 2015, 'Refugee experiences of general practice in countries of resettlement: a literature review', Br J Gen Pract. vol. 65, no. 632, e171-e176. doi:10.3399/bjGP15X683977.

Victorian Foundation for Survivors of Torture Inc. 2012, Promoting refugee health: a guide for doctors, nurses and other health care providers caring for people from refugee backgrounds, Victorian Foundation for Survivors of Torture Inc., Melbourne.

Kulkens M 2009, Access to specialist services by refugees in Victoria.

Reiner A and Webster K 2002, Refugee health and general practice development program final report

Victorian Foundation for Survivors of Torture Inc. 2004, Towards a health strategy for refugees and asylum seekers in Victoria, Victorian Foundation for Survivors of Torture Inc., Melbourne.

Christl B, Harris MF, Jayasinghe UW, Proudfoot J, Taggart J and Tan J 2010, 'Readiness for organisational change among general practice staff', Qual Saf Health Care, vol. 19, no. 5, :e12, doi:10.1136/qshc.2009.033373.

Pearce C, Shearer M, Gardner K, Kelly J and Xu TB 2012, 'GP networks as enablers of quality of care: implementing a practice engagement framework in a general practice network', Aust J Prim Health, vol. 18, no. 2, pp. 101-104, doi:10.1071/PY11121.

Stewart EE, Nutting P a., Crabtree BF, Stange KC, Miller WL and Jaen CR 2010, 'Implementing the patient-centered medical home: observation and description of the national demonstration project', Ann Fam Med. vol. 8, suppl 1:21-32, doi:10.1370/afm.1111.

Case study 2: recruitment of general practitioners and practice nurses for a pilot project

This case study demonstrates the role and collaboration between a number of key organisations that work with general practice at various levels.

The drivers

Cancer incidence is increasing due to an ageing population, however improvements in cancer detection and treatments have resulted in increasing numbers of people living with cancer, and beyond.

Cancer and its treatments can impact on physical, emotional and psycho-social health and on quality of life. Several studies have investigated shifting care from traditional specialist-only care to models that incorporate primary care. There is evidence that general practice is well positioned to provide post-treatment care to better meet the needs of cancer survivors.

The Australian Cancer Survivorship Centre (ACSC) was established at the Peter MacCallum Cancer Centre in 2008-09 to optimise the health and wellbeing of cancer survivors and their carers within PMCC.

The ACSC Strategic Plan 2013-16 identifies the need to work with the primary and community care sectors to improve survivorship care. This need is supported by the Victorian Cancer Survivorship Program evaluation findings which highlight a number of challenges with engagement by general practice and primary care.


The Australian Cancer Survivorship Centre approached relevant primary care organisations to inform the development of the clinical placement model and implementation of the project.

The players

The Australian Cancer Survivorship Centre piloted the placement project at Peter MacCallum Cancer Centre in 2015, and has led Phase II in 2016, involving Austin Health, Royal Women's Hospital and Western Health.

Promotional material was distributed through the Royal Australian College of General Practitioners, Australian Primary Care Nurses Association, Network Health Victoria, and Victorian-based Medicare Locals (now Primary Health Networks) and University of Melbourne Department of General Practice: VicRen (practice based research network.

Phase II promotional material was also provided specifically to Victorian-based community health services: ISIS Primary Care; Monash Link Community Health Service; and Inner East Community Health.

Participation - Phase 1: (16 GPs, 12 GPNs)

  • Western Victoria PHN 4 GPs, 5 GPNs: (Warrnambool (1GP/ 1GPN), Camperdown (3GPs/3GPNs), Heywood (1GPN))
  • North Western Melbourne PHN 10 GPs, 6 GPNs: (Inner East Community Health (8GPs/4GPNs) Bacchus March (1GP/1GPN) Altona (1GP/1GPN))
  • Eastern Melbourne PHN 1 GPN: (Bundoora (1GPN))
  • South Eastern Melbourne PHN 2 GPs: (Moorabbin (1GP), Elsternwick (1GP)

Participation - Phase 2:

  • Peter MacCallum Cancer Centre, 8 GPs and 5 GPNs
  • Austin Health 6 GPs and 3 GPNs
  • RMH/Women's 8 GPs and 2 GPNs
  • Western Health 3 GP and 2 GPNS

The Project Advisory Committee was established with representative experts from:

  • the Royal Australian College of General Practitioners
  • Australian Primary Care Nurses Association
  • Australian Association of Practice Managers
  • General Practitioners in clinical practice and those with an academic and research focus

The collaboration

The project recruited general practitioners and general practice nurses (working in general practice and community health settings in Victoria) and oncology specialists to work together in a 10-hour clinical placement.

The placement included attending multidisciplinary team meetings and outpatient clinics.

The aim of the placement program was to explore and evaluate if generalists and oncology specialists found that a clinical placement was feasible and of clinical and professional value, and provided an opportunity for knowledge and skills transfer.

Phase 1 Tumour streams:

  • Peter MacCallum Cancer Centre - Breast, Lower Gastrointestinal, Skin and Melanoma, Uro-oncology, and Late Effects.

Phase 2 Tumour streams:

  • Peter MacCallum Cancer Centre - As per Phase 1
  • Austin Health - Gastrointestinal, Genitourinary and Lung
  • Royal Womens Hospital - Breast and Gynaecology
  • Western Health - Breast, Colorectal and Genitourinary

Outcomes of Phase 1 included:

  • 63 per cent of generalist participants reported that program learning outcomes were entirely met, 37 per cent partially met
  • 70 per cent of generalist participants reported that personal learning needs were entirely met, 30 per cent partially met
  • 89 per cent generalist participants reported that the activity was entirely relevant to their practice, 11 per cent partially relevant
    Practices promoting successful outcomes
  • The attainment of RACGP Quality Improvement and Continuing Professional Development points provided confidence that the placement would offer a quality clinical experience
  • Participants who attended Late Effects Clinic were more likely to meet program learning outcomes - participants observed consultations for patients who had previously undergone curative treatment for cancer and required long-term surveillance for late effects.

The challenges

  • The placement program was observational and did not support extended open dialogue between generalists and specialists outside of the consultation setting.
  • There was limited opportunity for observation of post treatment consultations, except for the generalists that attended the Late Effects clinic.
  • Specialists reported a lack of opportunity for preplanning to better prepare for the placement and subsequent engagement with visitors
  • Learnings from Phase 1 were incorporated into Phase II, which is currently underway.

The results

  • Findings indicate that the program successfully met the aims of the pilot program. The program was demonstrated to be feasible.
  • All participants reported that the program was clinically and professionally valuable and they would recommend the program to a colleague.
  • Generalists and specialists described gaining a better understanding of each clinical group's contribution to cancer care and expressed a desire to better align care pathways to improve survivorship care.
  • Participants expressed enthusiasm to improve the quality of survivorship care and that the placement reinforced views that post treatment best-practice care would include general practice.

The key learning

  • Late Effects Clinic (where they occur) should be included in placements to best deliver a survivorship focused placement program
  • The clinical placement did facilitate knowledge and skills transfer and impacted positively on the confidence and empowerment for general practice to participate in shared care practice
  • Workflow constraints, workforce capacity and competency, inadequate communication to support clinical handover and generalists' knowledge gaps around short and long term consequences of treatment were identified as impediments to shared care in the post treatment phase.

Case study 3: GPs sharing the care of cancer patients following completion of treatment

The driversWith increasing numbers of cancer survivors and improved understanding of the range of challenges experienced post-treatment, new approaches to care are required. Current models of care are ill-equipped to cater for these demands.

Breast cancer is one of the most common types of cancer in our community. In response to a number of issues (including increasing demand on breast service outpatient clinics and patients' preferences for location of some aspects of post- treatment care) the Royal Melbourne Hospital and Royal Women's Hospital Breast Service along with the Western Health Breast Service piloted a survivorship program for patients completing definitive breast cancer treatment.


The Royal Melbourne Hospital and Royal Women's Hospital Breast Service team approached the GP lead at the Royal Women's Hospital and worked with the GP to develop the pilot proposal.

The GP liaison officer was appointed as the project manager and ensured GPs were involved in every aspect of the pilot.

GPs were members of the project steering committee and were able to advise on the development and implementation of the shared care model.

The players

  • The unit heads and staff (including breast care nurses) of the Breast Cancer Services at the Royal Melbourne Hospital, The Royal Women's Hospital and Western Hospital
  • The manager, staff and volunteers (breast cancer survivors) of BreaCan (an information and support service for people affected by breast or gynaecological cancers)
  • Inner North West Melbourne Medicare Local (GP rep)
  • GPs and practice nurses (of patients participating in the pilot)

The collaboration

Survivors with early breast cancer were risk stratified to shared care follow-up with GPs at the multidisciplinary meeting.

  • Participants were offered a face-to-face or telephone-delivered nurse-led clinic consultation for: education; psychosocial, physical and treatment-related concerns; referrals; and development of survivorship care plans.
  • Nurses facilitated shared care arrangements with nominated GPs Practices promoting successful outcomes
  • Risk-stratified pathways for transitioning to shared care or to discharge for GP follow-up were successfully piloted
  • Survivorship Care Plans were positively received and viewed as a valuable communication tool by survivors, hospital staff and GPs
  • Opt-out approaches to obtaining GP consent to participate in shared care/GP follow-up facilitated implementation
  • Nurse led clinics facilitated supportive care screening, tailored information provision, linkage with services and transition to GP follow-up.
  • A process for rapid access to a breast cancer specialist was developed and communicated to GPs to support patient and GP confidence in the shared care model
    The challenges
  • Preparing survivors early for what might be expected during survivorship and how to access assistance if problems arise is important. Early preparation for GP follow-up will help survivors accept shared care arrangements. Information resources could be developed to communicate these messages.

The results

  • More than 180 women participated in the pilot. As a result, aspects of care (e.g. prescription for routine investigations, allied health interventions, etc.) were transitioned into the community, reducing waiting times and hospital clinic congestion as well as improving access to timely, local appointments for women who received care with their GP
  • Shared care/discharge to GP follow-up models appear to be acceptable to low-risk cancer survivors
  • Breast Service staff, GPs and women reported that it is appropriate and convenient to engage in a shared care arrangement following completion of definitive treatment
  • With the shared care arrangements model, up to three fewer hospital follow-up appointments per year per patient were made, freeing up capacity.

The key learning

  • Most GPs are willing to provide cancer surveillance for low-risk survivors.
  • Establishing and communicating clear roles and responsibilities in survivorship care is essential.
  • If formal agreements of transfer of care are used, opt-out processes are easier to implement.
  • Aligning survivorship with chronic disease management frameworks and GP working models/processes is important.


Acting Manager, Cancer Reform, Cancer Strategy and Development
Telephone: 03 9096 2131

Case study 4: GP recruitment for work with vulnerable cohort

This case study highlights the role of a Primary Health Network (PHN) and the role played in connecting GPs to a project supported by a PHN GP Support TeamThe driversChildren entering Out of Home Care (OoHC) on Children's Court protection orders have experienced a significant level of child abuse and neglect that placed them at risk of harm and negative impacts to their health and wellbeing.

A 2005 study by Royal Australian College of Physicians recommended regular comprehensive health assessments for children in OoHC. Barriers to this being implemented previously were identified as lack of access, prolonged wait for services, poor coordination, poor communication and insufficient funding.

General practitioners (GPs) were approached to gauge their willingness and readiness to undertake health assessments for children living in OoHC. It was revealed that many GPs experience uncertainties about their roles with this vulnerable cohort. Ethical concerns, lack of medical history, professional development, medico legal issues, workforce and financial pressures and communication problems with CP services were identified as significant barriers.


The department approached Gippsland Primary Health Network (GPPHN) to be part of the pilot. GPPHN's defined role was to support GP engagement and connect GPs to the project to facilitate comprehensive referrals to the Multi-Disciplinary Team (MDT) clinics situated at the local community health services.

The players

  • Gippsland PHN (GPPHN), Central Gippsland Health Service (CGHS)
  • Department of Health and Human Services Child Protection
  • Inglis Medical Centre

The collaboration

The PTGH is a project of the Department of Health and Human Services in Victoria and is one of the top 10 priority projects under Victoria's vulnerable children - our shared responsibility: strategy 2013-2022. A pilot in Gippsland commenced in 2015.

The project provides a framework of health assessments and specialist services commencing with a general health check with a GP who can then refer on to a Multi-Disciplinary Team (MDT) clinic as required. The MDT comprises a paediatrician, psychologist and speech pathologist.

A Health Management Plan developed by the MDT is provided to the referring GP, CP and the Carer to support the ongoing management of the child's health.

GPPHN assisted with writing information sheets aimed at General Practice and facilitated meetings with Practice Managers to speak to the information and answer any questions. All printed material was emailed to practices for pre-reading.

Early unsatisfactory referrals indicated the initial messaging was not getting through to GPs and other clinic staff.

GPPHN coordinated clinical meetings disseminating specific clinical and referral information directly to GPs and other clinical staff. Representatives from Child Protection and the community health service also attended to answer questions and allay concerns.

Practices promoting successful outcomes

  • Face-to-face contact with GPs and other practice staff identifying the roles and responsibilities of respective practice staff for PTGH
  • Detailed clinical and referral pathway - presented by CP, GPPHN and CGHS
  • Consistent key messages with opportunity for Q-A
  • Separate checklists for GPs and Reception
  • Staff decided on an all practice 'system' to implement PTGH appointments
  • Relationship building and regular liaison between CGHS PTGH Nurse Coordinator and Inglis Medical Centre Practice Nurse provided valuable follow-up and greatly contributed to improved referrals.

The challenges

  • Confusion about referral to MDT clinic as it differs from usual method of referring to one specific practitioner
  • Concern over unknown Medicare numbers or children not registered and the financial and administrative implications for the practice
  • Concern over consent particularly re carrying out vaccinations and referrals to MDT Clinic specialists
  • Lack of health history/information provided by CP.


  • Further development of key messages addressing identified concerns to ensure the practices visited were well informed and encouraged to implement a whole of practice system
  • Direct presentation to GPs and all staff prior to any children being referred to clinic
  • Further support offered to practices not referring well
  • Feedback to CP re importance of gathering health information/history and supporting carers with information to attend appointments.

The results

Detailed referral to MDT Clinic received from GP including a comprehensive GP Health Check and health history for child with significant verbal communication deficits due to cleft lip and palate that was only partially treated and serious mental health issues.

Due to interim accommodation order and subsequent multiple placements, regular speech therapy and follow up surgery had not occurred. This also impacted negatively on child's education.

A serious disconnection in the handover from CP Case Manager to CP Case Manager and placement to placement and a lack of follow up of care when the child was returned to mother was identified. Release of information was an issue.

The child now has a Health Management Plan that sits with the medical clinic, CP and the carer.

Recommendations from the MDT

  • Ongoing paediatric review
  • Mandatory attendance at specialist Royal Children's Hospital Cleft clinic and required surgery
  • Dental review
  • Ongoing referral for speech therapy - alternative means of communication to help develop language
  • Cognitive assessment to exclude learning difficulty
  • Assessed for integration aide at school
  • Access to mother and siblings
  • Intellectual assessment
  • Ongoing sessions with Psychologist
  • Assessment by Occupation Therapist - motor skill and sensory development
  • Case planning meeting to coordinate care
  • Maintain links with Aboriginal heritage

The key learning

  • Development of stakeholder relationships to ensure everyone is fully informed and systems in place in a timely manner. Cooperation, communication and regular liaison between all stakeholder groups is essential.
  • Keep key messages simple and refer to more detailed information
  • Complete whole of practice visits to fully inform GPs and practice staff and encourage implementation of a whole of practice system before first PTGH GP appointments are made
  • Gather comprehensive health information/history prior to MDT clinic appointment
  • Fully explain the PTGH initiative to carers and support them to facilitate the recommendations in the health plan
  • The importance of release of all health information and comprehensive handover when placements and CP case managers change.


Website: Gippsland Primary Health NetworkExternal Link

Case study 5: collaboration with a statewide agency

This case study is an example of collaboration between the department and a statewide agency to better manage and administer programs and support to rural general practice.

The drivers

A review of the Rural Medical Workforce Programs was undertaken early in 2015 to determine the relevance and impact of the current rural medical workforce programs, as well as their alignment with program objectives and government and branch policy.

The review recommended that consideration be given to outsourcing management to a single external agency, so as to achieve the desired program outcomes, and to eliminate variabilities in program administration.


Following the review the department selected Rural Workforce Agency Victoria (RWAV) as the preferred agency to manage the rural medical workforce programs because of their role in facilitating integrated rural training pathways, their organisational capability and stakeholder engagement.

RWAV has a focus on health workforce in rural areas, including nursing and allied health, through its Commonwealth and State funded programs.

The agency had already been managing the Rural Locum Scheme, Continuing Medical Education and Continuing Professional Development programs, Post Placement Support and Training Coordination and Rural Recruitment, for the department.

The players

RWAV is a non-profit government organisation specialising in recruitment, workforce support and retention, and facilitating outreach services across rural, regional and Aboriginal communities in Victoria.

The collaboration

Following selection of RWAV to manage the rural medical workforce programs stakeholder meetings were held to discuss the best approach to ensuring continued support of rural general practitioners. This meeting included the Regional Training Organisations, who are responsible for delivering the Australian General Practice Training program.

Ongoing communication between all stakeholders regarding the rural medical workforce programs will continue following RWAV's management of the programs commencing 1 July 2016.

Practices promoting successful outcomes

As the handover of administration of programs to RWAV did not officially take place until 1 July 2016, results remain to be seen.

However, it is expected that external administration of rural medical workforce programs would assist in focusing the department's Medical Workforce Unit on current and emerging government priorities.

Furthermore, external management of the rural medical workforce programs will afford an opportunity to align and integrate the rural programs to achieve better consistency, efficiency and effectiveness; as well as contribute to medical workforce planning by identifying broader health workforce needs.

The challenges

The challenges included:

  • Managing stakeholder expectations and personalities.
  • Identifying with precision each stakeholder's responsibilities.
  • Training year (calendar year) vs financial year funding by the department.

The results

As the handover of administration of programs to RWAV did not officially take place until 1 July 2016, results remain to be seen but work to date has reassured the department that this change in management will prove effective and better target support for rural medical practitioners.

The key learning

Statewide agencies are well placed to administer programs and support general practices across Victoria.

Case study 6: working with a disease-specific organisation to increase screening in general practice

This case study is an example of pathway development involving multiple players at both systems and agency level.

Activity related to program design and implementation seeking to influence the work of general practice.The study also draws attention to the role of a primary health engagement officer.

The drivers

The overall driver was the need to work with primary care stakeholders to support health professionals implement an absolute risk approach in line with best practice guidelines.


The Heart Foundation and National Stroke Foundation wanted to work with key stakeholders at a local level (south-eastern metropolitan Melbourne including the LGAs of Dandenong, Cardinia and Casey) to implement an effective screening and management program that would reduce stroke and heart attack.

Funding was provided by the Department of Health and Human Services, for local relationships to be established to support agencies to undertake service mapping, build referral pathways and re-design their systems to better identify patients who are at high and moderate risk of cardiovascular disease (CVD) and to refer these patients into risk reduction programs such as Life! Helping you prevent diabetes, heart disease and stroke program (Life! Program).

The players

The roles of the key project partners were as follows:

Systems level

  • Peak bodies - Heart Foundation (Victoria), National Stroke Foundation and Diabetes Australia - Victoria
  • South Eastern Melbourne Medicare local /South Eastern Health Providers Association - the conduit to engage with GP practices and provide practice support
  • Enliven - South East Healthy Communities Primary Care Partnership (PCP) - service mapping and the development of a cardiovascular risk prevention pathway

Agency level

  • Monash Health Community (CHS) - community based risk detection and awareness
  • 9 GP practices - project participation
  • 10 pharmacies - project participation
  • LGAs of Greater Dandenong, Cardinia and Casey - to aid community engagement

The collaboration

As above.


  • Implemented a comprehensive pathway that identifies individuals at risk of CVD and type 2 diabetes and appropriately refers them into primary care services using absolute risk as a best practice approach.
  • Participating general practices introduced protocols to target appropriate patients for risk screening and referral.
  • The Life! Program was promoted as a key referral point for people at moderate and high risk of CVD.

Practices promoting successful outcomes

  • Strong collaborative networks
  • Shared commitment
  • Roles and responsibilities clearly defined/TOR
  • Building interdependent systems to address issues and opportunities
  • Change champions (GPs, PN or PM) at an agency level
  • A targeted approach using clinical audit tools to identifying risk
  • Capacity building to support practice change - practical support
  • Engagement of key agencies to support 'grass roots' participants

The challenges

  • Short time frame (five months) for implementation phase of the project
  • A new area of work using an absolute risk approach for the participating practices. Extra time needed in reviewing/cleaning data and adopting the best systems for each practice.

The results

  • Identified 45 relevant prevention programs
  • Embedded an absolute risk approach in all participating general practices including an Aboriginal Health Service
  • Assessed 727 patients in General Practice with 267 lifestyle referrals initiated
  • Screened 457 people in pharmacies with 180 lifestyle referrals initiated
  • Implemented an agreed South East Melbourne Cardiovascular risk prevention pathway to support identification of at risk individuals, referral into general practice, and local referral pathways into community management programs (including Life!) for patients who are identified as low, moderate and high risk of CVD.

The key learning

The importance of being flexible to adapt to local needs - using a place based approached.

The guidelines provide a blueprint of recommended care, how this is implemented in practices should not be too prescriptive as each general practice is unique and has different resources and patient needs.

Practice support is vital in achieving this.


Primary Health Engagement Officer

Case study 7: working with a disease-specific organisation to change/influence general practice

This case study is an example of an initiative to influence the work of general practice and increase referrals to a state-funded service.

It highlights the role of primary care engagement staff within a disease-specific organisation.

The drivers

  • The collaboration between general practice and Life! provides an opportunity to engage with, promote and support referrals to the program.


Life! staff, specifically the Primary Care Engagement Team, approached the GP clinic.

The players

  • General practitioners
  • Practice nurses including nurse coordinator
  • Practice manager
  • Practice staff (administration staff)
  • Life! staff, specifically the Primary Care Engagement Team
  • Life! program workforce including providers, facilitators and health coaches

The collaboration

  • Engaged at the clinician level and broader level including general practice staff and management
  • Life! integrated practice support with support from our primary care engagement team and centralised referral service
  • Combination of on-site visits and phone/face-to-face education sessions to maximise opportunities to train staff, address any concerns or issues and increase referrals into the program.

Practices promoting successful outcomes

  • Building capability and leveraged on capacity within the general practice including via incentives (financial and non-financial)
  • The general practice participated under the Life! case finding agreement that provided a referral incentive. The clinic was incentivised based on their referral performance to Life! program
  • Leveraged on medical software to detect high risk patients who may eligible for the Life! program so that the patients can be screened and referred to the program
  • Life! resources, including brochures and posters, which the general practice displayed in the waiting room to encourage waiting patients to learn more about chronic disease prevention and to do the AUSDRISK test. This encouraged them to discuss their risk with their GP and/or practice nurse
  • High risk and eligible patients were supported through the screening and referral pathway and therefore generally enrolled to participate in the Life! program, either a local group course or the telephone health coaching service.

The challenges

  • Building and leveraging on existing capacity within the general practice
  • Staff turn-over within general practice specifically practice nurse.
  • Engagement requires both parties to consistently make best endeavours and this was not always attained to its maximum at times.
  • Uncertainty regarding Life! program funding and delivery continuation.

The results

  • Increased awareness of the Life! program for high risk and eligible patients
  • Victorians identified at high risk through systematic risk assessment (assessed using AUSDRISK tool and Absolute Cardiovascular Disease Risk assessment)
  • Early intervention for those at high risk of type 2 diabetes and/or cardiovascular disease
  • Better communication, information and practice support has led to an increased and sustainable GP referral pathway to the Life! program.

The key learning

  • Direct engagement with the general practice is dependent on the context that they operate in e.g. clinic size, operating hours, staff and resource capacity.
  • To strengthen engagement across the general practice, continuous practice support that addresses gaps (such as responding to educational needs) and frequently engaging and supporting the clinic was critical.

Case study 8: recruitment of practices for a trial of care coordination in chronic disease management

This case study is an example of trialling an initiative within general practice involving a selection of general practices.The driversThe My Health Home Model of Care is a person centred, holistic model of care coordination and was designed as a quality improvement activity to pilot an extended care coordination model.The project was a response to the population as determined through the Hume Medicare Local (HML) Population health report 2013 and the Chronic Disease Pathways Project report 2013.


The Chronic Disease Pathways project showed that:

  • patients required access to a range of services to support them
  • there was a local/regional need for services to be integrated and coordinated
  • patient information must be communicated between health care providers throughout care in a clear and safe manner
  • general practice must be the central point of communication for patient care.

In response to these findings the Hume Medicare Local (HML) undertook to implement and evaluate the My Health Home Model of care coordination

The players

  • Hume Medicare Local (HML)
  • Department of Health Hume Region
  • Hume Health Services Partnership
  • Community agencies
  • Hospitals
  • Local government
  • General practice
  • Specialists

The collaboration

Eleven local general practices obtained seed funding from the HML to participate in piloting the My Health Home Program.

A robust and equitable tender process was undertaken to engage general practice. It was essential that a commitment to improving chronic disease care was demonstrated.

A multi layered orientation program was provided ranging from a five-minute presentation that provided GP specific information, a 20-minute overview, and audio files describing different scenarios.

Across the practices there were differing starting points depending on understanding and readiness.

The 11 general practice pilot sites had access to care coordination services of a day a week over six months across five Shire areas.

Practices promoting successful outcomes

  • The use of the preferred method of general practice engagement via an Expression of Interest process that is well supported through access to clear and concise program information and guidelines
  • An understanding of change management together with a well thought through orientation program
  • Communication - practices who introduced a robust internal program referral process and an established agreed communication structure were more successful
  • Skill and expertise of the care coordinators
  • Seeding funding for the practices allowed time for education and implementation of CDM systems.

The challenges

The early stages of the project focussed on presenting the opportunity to general practices to undertake a pilot program.

A collection of detailed resources was developed including Program Guidelines and visual model diagrams, accompanied by a practice visit.

It was identified that this engagement process was very time consuming and was improved though an expression of interest and tender process.

This enabled delivery of information across a wide audience, contributed to messaging consistency, and expedited and formalised the process considerably.

It also better supported contract procurement processes.

An identified barrier was change management.

The person centred and goal orientated service delivery model required a mind shift.

The practices that were the most receptive were those at a tipping point looking for change to enhance and improve current CDM systems.

From this point the project looked at practice readiness indicators to enhance understanding of the program and how it may integrate into general practice.

Orientation program covered the willingness to adjust and change with a five-minute PowerPoint presentation that focussed on the GP specific components of the program with further information provided progressively.

Included audio files that described both organisational and patient focussed scenarios.

Fluctuating understanding of the MBS was observed early in the program orientation process.

Further MBS focussed resources were needed.

Care Coordinators (staff already employed by a practice) were sometimes taken away from their responsibilities to undertake clinical roles in times of staff shortage.

Reality of a dual position within an organisation.

The results

  • Contributed to increasing services efficiency across chronic disease management systems
  • Positive outcomes across patient satisfaction and perception
  • Significant increase in access to services and utilisation of evidence based guidelines to support CDM pathways and processes
  • Increase in formal local agreements to support efficient shared care processes and continuity of patient care across agencies
  • Demonstrated efficiency across patient registers and recall/review processes
  • Increased MBS claiming data - program demonstrated sustainability across MBS
  • Also contributed to sustainability through increased awareness and understanding of chronic disease management within the practices
  • A number of the practices are planning to continue the program or components of the program.

The key learning

  • Access to training offered and the skill and expertise of a care coordinator did provide a positive and contributing effect on the program.
  • Further research and investigation is required around patient self -management and clinical outcome data.
  • Although proven to be sustainable in relation to MBS a longer timeframe post implementation to demonstrate full program potential would have been beneficial.
  • Education, preferably local face to face workshops on appropriate utilisation of MBS would be beneficial.

Reviewed 09 March 2022


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