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Chronic Care
 

Equal Access for the Culturally and Linguistically Diverse

Equal Access for the Culturally and Linguistically Diverse

The appointment booking process for clients accessing the Fairfield Orthopaedic Hip and Knee Service was modified to enable the Culturally and Linguistically Diverse (CALD) population greater access to the service.
Fairfield Hospital
Added: 19 October 2018|Last updated: 20 November 2018
Home-Based Subcutaneous Immunoglobulin Replacement Therapy

Home-Based Subcutaneous Immunoglobulin Replacement Therapy

Liverpool Hospital is implementing a home-based subcutaneous immunoglobulin replacement therapy program for patients with impaired immune systems.
Liverpool Hospital
Added: 28 May 2018|Last updated: 21 June 2018
Complex Care Coordination in NSW Emergency Departments

Complex Care Coordination in NSW Emergency Departments

Royal North Shore Hospital is developing a clinical pathway for people who frequently present to hospital emergency departments with chronic pain and complex conditions, which will be rolled out across the state following evaluation of the pilot program.
Royal North Shore Hospital
Added: 23 April 2018|Last updated: 8 May 2018
Partners in Care

Partners in Care

This project supports staff who are trained in health coaching but are not providing it to patients on a regular basis. It also introduced an evaluation framework to continually assess the training and support needs of staff in South Eastern Sydney Local Health District.
Added: 24 April 2018|Last updated: 3 May 2018
Specialist Medical Clinics for Rural Aboriginal Medical Services

Specialist Medical Clinics for Rural Aboriginal Medical Services

Specialist medical clinics were established for Aboriginal people with chronic disease who live in rural and remote areas of Hunter New England Local Health District
John Hunter Hospital
Added: 29 January 2018|Last updated: 13 February 2018
Get It Together: For People with Multidisciplinary Healthcare Needs in the Community

Get It Together: For People with Multidisciplinary Healthcare Needs in the Community

This project pulls together multidisciplinary teams around their clients, as it has been shown that when people are included in care that is coordinated, they have better health and wellbeing.
Nepean Blue Mountains Local Health District
Added: 28 November 2017|Last updated: 15 December 2017
Hit the Ground Running: Improving Access to Pulmonary Rehabilitation

Hit the Ground Running: Improving Access to Pulmonary Rehabilitation

This project aimed to improve access to pulmonary rehabilitation and embed it as standard practice after admission to Coffs Harbour Health Campus for exacerbation of chronic obstructive pulmonary disease.
Coffs Harbour Health Campus
Added: 27 November 2017|Last updated: 15 December 2017
From Medical Excellence to Personal Confidence

From Medical Excellence to Personal Confidence

St Vincent’s Hospital Sydney reviewed its Hospital In The Home service and implemented a number of improvements, including care pathways, inclusion and exclusion criteria, online referral processes, communication among healthcare teams and shared care planning with patients.
St Vincent's Hospital
Added: 2 December 2016|Last updated: 16 December 2016
Improving the Diagnostic Process for Patients with Mitochondrial Disease

Improving the Diagnostic Process for Patients with Mitochondrial Disease

This project developed next-generation sequencing protocols and a bioinformatics platform for diagnosing mitochondrial disease, as well as a diagnostic pipeline that improved the speed and accuracy of diagnosis.
Northern Sydney Local Health District
Added: 19 October 2016|Last updated: 2 November 2016
Hospital in the Home: An Innovative Partnership Model

Hospital in the Home: An Innovative Partnership Model

This project developed a new model of care for its Hospital in the Home (HITH) program, by integrating the services delivered by ambulatory care and community health nursing teams.
Campbelltown HospitalCamden Hospital
Added: 15 September 2016|Last updated: 30 September 2016
Plan Early: My Future Care

Plan Early: My Future Care

This project delivers advance care planning to patients with end-stage chronic lung disease, by implementing staff training, standardising work practices for Advance Care Plan documentation, engaging general practitioners and using an evidence-based tool that predicts the risk of death within 12 months.
Prince of Wales Hospital
Added: 16 August 2016|Last updated: 20 September 2016
Show Me The Plan

Show Me The Plan

JH&FMHN developed a streamlined chronic disease process that addressed the barriers to completing a multidisciplinary care plan, by engaging frontline clinicians.
Justice Health and Forensic Mental Health Network
Added: 12 February 2016|Last updated: 4 March 2016
Singing to Health: A Choir for People with Neurological Communication Disorders

Singing to Health: A Choir for People with Neurological Communication Disorders

The War Memorial Hospital Waverley created a weekly social choir led by a volunteer music therapist, for outpatients with chronic communication impairments due to acquired and progressive neurological deficits. The choir supported the health of individuals, by building partnerships and facilitating continuity of care.
War Memorial Hospital
Added: 27 January 2016|Last updated: 10 February 2016
Care Coordination Screening and Triage

Care Coordination Screening and Triage

This project implemented a screening and triage tool within the outpatient cancer service at Illawarra Shoalhaven Local Health District, to improve the care coordination of patients during their treatment journey.
Illawarra Shoalhaven Local Health District
Added: 6 October 2015|Last updated: 21 October 2015
Far West Chronic Disease Prevention Group

Far West Chronic Disease Prevention Group

A monthly Chronic Disease Group was established in Broken Hill, where clinicians tested participants for chronic disease risk factors and provided group education sessions that empowered participants to manage their own health.
Far West Local Health District
Added: 21 September 2015|Last updated: 20 October 2015
An Innovative Allied Health Approach to Cancer Care Services: Removing the 'Band-Aid Effect'

An Innovative Allied Health Approach to Cancer Care Services: Removing the 'Band-Aid Effect'

Nepean Cancer Care Centre (NCCC) was established in 1998, setting up a comprehensive specialised interdisciplinary allied health team to support the care needs of the cancer patients throughout their cancer journey. Allied health services are experiencing the demand of a growing cancer care service. This project is working to ensure the most efficient, effective use of allied health resources to support the best patient journey....
Nepean Blue Mountains Local Health District
Added: 18 August 2015|Last updated: 25 August 2015
Developing a Young Adult Diabetes Service

Developing a Young Adult Diabetes Service

This project developed a specialist diabetes service for people aged 16 to 25, at The Tweed Hospital in Northern NSW Local Health District.
The Tweed Hospital
Added: 2 June 2015|Last updated: 16 June 2015
Chronic Disease Oral Health Pilot Project

Chronic Disease Oral Health Pilot Project

A Chronic Disease Oral Health Service has been established at Royal North Shore Hospital (RNSH), with a dental officer and oral health therapist. The service provides an expedited course of dental care with a strong focus on oral hygiene for chronic disease patients. A referral pathway to this clinic has been implemented using a referral form that is completed by chronic disease services....
Royal North Shore Hospital
Added: 18 May 2015|Last updated: 25 May 2015
Active Kyogle

Active Kyogle

Active Kyogle was a three-year federally-funded chronic disease prevention project which relied on the community to decide the health priorities and collaborative partners to plan and deliver the interventions. Active Kyogle empowered the community to implement a health promotion program to prevent chronic disease focusing on projects that increase healthy eating, physical activity and reducing social isolation.
Northern NSW Local Health District
Added: 5 February 2015|Last updated: 11 February 2015
Lymphoedema Management in Occupational Therapy

Lymphoedema Management in Occupational Therapy

This approach is focused on facilitating early intervention with improved awareness of the chronic condition and referral pathway. Solutions aim to empower patients with the ability to independently self-manage with support of an integrated care approach with community health and EnableNSW to minimize long episodes of care with the outpatient service. Improved efficiencies with a service agreement and planned patient journey aim to help meet the demand of the service and reduce the wait time for treatment....
Sydney Local Health District
Added: 4 December 2014|Last updated: 8 December 2014
Unlocking the door to chronic disease management in custody

Unlocking the door to chronic disease management in custody

This program aims to improve the health of patients with chronic disease whilst in custody as well as connecting them to community services upon release to ensure their continuum of care. Following three years of implementation, this current initiative relates to the redesign of the program to increase patient access through improved identification of patients with chronic disease and the application of risk stratification to measure a patient’s risk of hospitalisation for appropriate management of care....
Justice Health and Forensic Mental Health Network
Added: 5 December 2014|Last updated: 8 December 2014
Holistic Health for Mental Health Clients

Holistic Health for Mental Health Clients

The co-located General Practice clinic has cared for over 100 consumers who had not seen a General Practitioner in the last 12-18 months. In partnership with existing metal health services, the co-location model ensures community mental health services work collaboratively with the GP to improve the health status of community mental health clients, providing seamless and continuous care. This initiative increases community access to GPs, Psychiatrists, Clinical Psychologists and other Allied Mental Health Professionals for Mental Health Care....
Sydney Local Health District
Added: 21 November 2014|Last updated: 21 November 2014
Far West Mental Health Recovery Centre

Far West Mental Health Recovery Centre

The Far West Mental Health Recovery Centre (FWMHRC) is public mental health admission facility to be operated in partnership with a Community Managed Organisation (CMO) in NSW. The FWMHRC is a 10-bed unit in the grounds of Broken Hill Health Service. It provides step-up step-down care to people requiring support to overcome mental ill health. The inclusion of the FWMHRC into the spectrum of integrated mental health and drug and alcohol programs in Far West NSW has solved a number...
Neami National
Added: 23 October 2014|Last updated: 23 October 2014
Advanced Care Planning in the Ballina Renal Service

Advanced Care Planning in the Ballina Renal Service

The Ballina Haemodialysis Unit is a seven chair satellite facility providing 84 dialysis treatments weekly. The majority of 28 patients are aged 70 years or older with comorbidities including diabetes, cardiac, cardiovascular and haematological conditions. The aim of the project was to raise the awareness among our patients of Advance Care Directives (ACDs) and to reach a compliance of 80% by Christmas 2010. We have now achieved 84% compliance with the NSW Health ACD Policy. Implementation of the policy required...
Ballina District Hospital
Added: 28 August 2013|Last updated: 10 October 2014
Care To Come Home: CaTCH

Care To Come Home: CaTCH

A new Model of Care is being introduced at Lachlan Health Service (LHS) – Forbes and Parkes. Hospital in the Home (HITH) provides a choice of care at home or at a daily clinic instead of being admitted to hospital. This will provide quality care with less disruption for a smooth patient journey.
Western NSW Local Health District
Added: 19 August 2014|Last updated: 26 September 2014
48 Hour Follow Up Evaluation

48 Hour Follow Up Evaluation

Aim: To determine what proportion of eligible patients receive follow up; and whether the provision of enhancement funding has had any impact on rates of follow up.&...
Benefits: The 48 Hour Follow Up program was conceived as a result of the NSW Walgan Tilly Redesign project, which aimed to address gaps in health care and to improve...
5 January 2016
1 Deadly Step

1 Deadly Step

Aim: The 1 Deadly Step program promotes screening, early detection and follow up of chronic disease in Aboriginal communities in NSW. The unique component of 1 Deadl...
Benefits: The 1 Deadly Step project is an initiative of the Chronic Care for Aboriginal People Program (CCAP). This project demonstrates how the CCAP Model of Care c...
4 January 2016
Care of Confused Hospitalised Persons (CHOPs) program

Care of Confused Hospitalised Persons (CHOPs) program

Aim: Provide simple strategies to improve the care outcomes of older patients with confusion in NSW hospitals, through:increased staff knowledge and skills to i...
Benefits: Increased screening, improved risk assessment and more appropriate treatment and management of confusion.Increased awareness, knowledge and skills of staff to b...
14 August 2015
The Musculoskeletal Primary Health Care Initiative

The Musculoskeletal Primary Health Care Initiative

Aim: The Musculoskeletal Primary Health Care Initiative aims to plan, implement and evaluate a ‘one-stop’ program of care within primary care settings fo...
Benefits: The Musculoskeletal Primary Health Care Initiative proposes the benefits will be that validated musculoskeletal models of care can be provided in primary health...
9 February 2015
Palliative and End of Life Care: A Blueprint for Improvement

Palliative and End of Life Care: A Blueprint for Improvement

Aim: The Blueprint aims to guide services and Local Health Districts in constructing their own localised models of care.
Benefits: The Blueprint emphasises the need for an integrated approach to care whereby relationships between specialist palliative care providers and care providers acros...
22 February 2016

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