2018 Snapshot

Sharing success

Since our very first day as a Primary Health Network, back on 1 July 2015, we have made building partnerships our number one priority.

We’ve done that because it is only through genuine collaboration that we have a chance of meeting the goals we’ve been set, both by the federal government and by ourselves.

These goals have always been ambitious. We aim to provide better health, every day in every way - not by directly providing new services or infrastructure, but by connecting, supporting and improving the health system that we have, to make it the health system we need.

It takes hard work, and patience, the willingness and ability to try new things, and to try again if those things don’t work out. Most of all it requires engaging with our health community, to identify what the needs are, who is best able to meet those needs and what we can do to help them make it happen.

After three years of establishment and growth as a commissioning organisation, 2018 is the year when this work has started to come to fruition.

The support we have provided and the services we have commissioned are starting to make a tangible impact on the health of our community, and on the way both people and practitioners experience our local health system.

We’re proud of the work we’ve done this year, but most of all we’re proud that it is not our work alone. Productive and respectful partnerships are the thread that binds together all the activities highlighted in this review. They would not exist, and certainly would not be as successful, without the work and support of our many partners.
Below you'll find a snapshot of some of the work we've been doing with our partners this past year to improve health in our shared community.
We’re looking forward to working ever more closely with partners old and new in the years to come, building on our shared success and meeting the growing health challenges facing our region, together.

Adjunct Associate Professor Christopher Carter, CEO

The objectives outlined below are our blueprint for better health in Melbourne’s north and west, directing not only what we do as an organisation but also how we do it.

These goals guide us to ensure we are always striving towards better health, every day in every way.

Rising rates of chronic diseases, like diabetes, hepatitis and chronic kidney disease, is one of the biggest challenges to our health system. We are supporting evidence-based programs and services to reduce the impact of chronic disease on individuals and the community.


CareFirst is a six-month behaviour change program, delivered by Medibank, that upskills general practice teams to better manage chronic conditions. It also provides patients with tools and approaches to help them achieve better health outcomes.

  • 1110 health coaching sessions attended
  • 27 practice nurses trained
  • 162 patients graduated program
“Excellent - has helped me improve my life greatly”

CareFirst patient

Pharmacists in general practice

Non-dispensing pharmacists have been integrated into general practices in Caroline Springs, North Richmond, Deer Park and Keilor to support Quality Use of Medicines.

The pharmacists are working with staff and patients to review individual medication use and safety, improve staff prescribing and carry out practice-wide Drug Utilisation Reviews – a system of ongoing, systematic, criteria-based evaluations of drug use.

The pharmacists have conducted:

  • 110 practice-focused activities
  • Hundreds of testing, MBS, liaison and collaborative activities

Stepping up diabetes

The Stepping up model builds the capacity of general practice and practice nurses to deliver intensified diabetes treatment and management in primary care, improving patient outcomes and experience.

15 general practices were recruited to the program in 2017-18, with 15 GPs and 19 practice nurses participating. This led to:

  • 21 of these patients commenced on insulin treatment
  • 9 patients not part of the program also commenced on insulin

As much as we believe in improving health for everyone in our region, not everyone gets the same opportunities when it comes to health. That’s why we work with priority populations, like our LGBTIQ, culturally and linguistically diverse and Aboriginal and Torres Strait Islander communities - to ensure they can receive the best possible care.

Bedaya Sehaya Refugee Healthy Living

Newly arrived refugees in Hume, Melton and Brimbank have got a headstart on understanding the Australian health system thanks to the ‘Bedaya Sehaya Refugee Healthy Living’ program.

The program trained Syrian and Iraqi bicultural workers to deliver information about the health system to refugee communities in a culturally appropriate way.

  • 90 sessions were conducted across six local government areas
  • Topics included navigating the health system, immunisation, healthy eating, exercise, refugee health assessments and more

Alcohol and other drug commissioning

Four new programs are providing targeted alcohol and other drug treatment for people from culturally and linguistically diverse and LGBTIQ communities across our region.

The programs focus on responding to the diverse needs of these groups with culturally sensitive, appropriate and accessible care.

  • Stimulants and hallucinogens, alcohol and cannabis were the top three concerns for clients

General practice is at the heart of a strong primary health care system. We are helping increase capacity in general practice to provide best practice, evidence based care in a responsive and sustainable way, supporting improved patient and practitioner experience, reducing costs and improving care outcomes.

Strengthening Care for Children

Paediatricians from the Royal Children’s Hospital have been placed into five general practices across our region, to examine the impact on child health outcomes from providing greater specialist support in treating and managing paediatric patients.

Practices receive a co-located paediatrician on a weekly basis for patient co-consultations, monthly case conferences with the paediatrician and can access the paediatrician by phone and email for same-day advice.

Preliminary results from the pilot study program show:

  • 44 GPs and 2 nurse practitioners have been involved
  • More families are ‘completely confident’ their GP could provide general care for their child (78.3% to 94.2%)
“I have learned a lot in an enjoyable format, and have changed the way I practice in many ways, including how I take a history from patients, the assessment tools I use, and the online resources I use including the RCH guidelines and Health Pathways.”

Participating GP

Statewide Paediatric HealthPathways Project

New online paediatric HealthPathways are delivering better, safer care for children in general practice, while also reducing the pressure on emergency departments.

HealthPathways on respiratory and gastrointestinal conditions were released in January, with more pathways covering the unwell child, neurology, ear, nose and throat (ENT), and allergy conditions available from October.

  • Pathways were viewed 4991 times between February and August 2018
  • 160 health, medical and subject matter experts contributed to the process of pathway development and review

There’s no point having high-quality medical and health services if they can’t be accessed by the people who need them. We’re building stronger links between local health providers, supporting the expansion of services in areas of need and giving local people the knowledge to access the right services for them, at the right time.

Discharging Wisely

The Discharging Wisely project has helped the Western Health diabetes clinic meet greatly increased demand, with new approaches implemented to increase capacity to see new referrals, better manage existing resources and improve clinical handover to general practice.

Between July 2017 and June 2018:

  • The number of new patient appointments at outpatient clinics doubled
  • The waitlist for diabetes clinics decreased substantially, even while referrals increased significantly

Tiny Hearts

NWMPHN has funded Tiny Hearts training courses in infant and child first aid for parents and caregivers in our region. The training covers how to respond to a range of medical situations and information about the after hours health care options available in our area.

  • 13 sessions were held in Melton, Broadmeadows, Caroline Springs and St. Albans
  • There were large, sustained increases in participant knowledge and capability
Until the session, I think I would have thought twice about whether I could actually administer first aid that could save his life. While I hope I never need to find out, I do think that in the case of an emergency, I would be ready and willing to act.

Belinda Fitzpatrick, Tiny Hearts First Aid participant

With one in five people experiencing a mental illness every year, and mental health being the most common reason to visit a GP, the way we care for mental health needs to change. We are leading that change by placing the person at the centre of their own care every step of the way – from identifying needs and barriers, to designing and delivering targeted and responsive services.

Our system of care

The system of care brings together mental health, alcohol and other drug, suicide prevention and dual diagnosis services in a single online portal that can be accessed by practitioners and patients. Services can be filtered according to location, target population, treatment type and complexity to meet individual needs, even as those needs change over time.

Care is coordinated through our CAREinMIND service system, which provides access to a range of services targeted at specific populations and delivered by contracted organisations across the region.

  • Interpreter used - 1383
  • People who identify as LGBTIQ - 879
  • Aboriginal and Torres Strait Islander people - 762
  • Children and young people - 5625

Place-based suicide prevention trials

We are establishing community-led support networks in Brimbank, Melton and Macedon Ranges to find locally relevant solutions to suicide in those areas.

People with lived experience of suicide, community leaders and service providers are coming together to raise suicide awareness, improve suicide prevention skills and service coordination, and ultimately reduce deaths.

As a commissioning organisation, we rely on accurate information about the health of our communities to identify where our funding and support will have the greatest impact. We don’t just rely on gathering the best quality data and statistics to do this. We also engage our health partners and community representatives at each step of the process, to make sure we are giving our communities what they actually need, not just what we think they need.

Health Needs Assessment

A comprehensive overview and analysis of the major health issues facing our region, produced in collaboration with our partners and community representatives.

Produced yearly, the latest edition includes individual profiles on our key health priorities, including mental health, children and families, chronic disease and more.

You Said™

You Said™ surveys consumers at three points throughout their health care journey, to find out more about their experience of the care they receive and their outcomes of care.

Responses are tracked through an online portal and analysed to identify areas of strength and need for service improvement.

We hold ourselves to the highest levels of governance and accountability, including through our Board and Council processes, multiple checks and balances built into our commissioning cycle, regular audits and staff training. We do these things not only because they are the right thing to do, but because they make us a more robust, equitable and effective organisation.


Our Clinical Council and Community Advisory Council help us align our work with the needs and expectations of health providers and the community.

They play an important role in both guiding the direction of the organisation and providing critical review of our activities.

As an established part of our local health system, we are now able be part of challenging conversations within the sector as it works to change for the better.

Reform is never easy, but by working through the issues and challenges together we have established partnerships that are already delivering tangible results, for the system and the community.

“I welcome this new resource as most of our medical providers receive little or no training on understanding the issues faced by trans, gender diverse or non binary people.
"I hope GP’s and other medical providers will access this informative resource and meet the needs and expectations of those whose gender identity does not meet society’s expectations.”

Brenda Appleton – Chair, Transgender Victoria

Key joint projects: Development of ‘Primary Health Care for Trans, Gender Diverse and Non-binary people’ online training module.

“Working collaboratively with North Western Melbourne PHN to develop localised videos for the place-based suicide prevention trials has been a great experience.
"The team provided the basis for a strong working relationship and showed incredible energy and enthusiasm during the making of these videos.”

Dr Bruce Bolam, Chief Preventive Health Officer, Department of Health and Human Services

Key joint projects: Place-based suicide prevention trials.

“The PHN partnered with Melbourne Health on a multi-dimensional pilot program aimed at improving the quality, safety and consistency of care for Residential Aged Care Facility residents.
"The collaboration has demonstrated that enhanced RACF staff education can directly contribute to a reduction in emergency department presentations and increase the time to readmission.”

A/Prof Genevieve Juj, Director – Allied Health, Melbourne Health (pictured at right)

Key joint projects: PRoACT project to reduce avoidable admissions at Royal Melbourne Hospital for aged care residents.

"Western Health have had a mutually beneficial partnership with the NWMPHN in our Diabetes Clinic 'Discharging Wisely' Project.
"Over 12 months we have increased the number of new patients we see in our hospital clinic and reduced waiting times.
"We have also been able to assist and empower GPs and diabetes educators through upskilling via practice visits, and an interactive evening seminar."

Dr Dev Kevat – Endocrinologist, Western Health

Key joint projects: Discharging Wisely, helping help the Western Health diabetes clinic meet greatly increased demand.

As much as we value them, our health community is more than just our active and committed partners. That’s why we don’t let a day go by without contacting multiple health providers in our region, to see how we can support their work, how we can engage them in quality improvement and development, and to seek their input into our activities and priorities.

The most common request from stakeholders through these contacts was for general engagement and practice support. That’s why we engaged with 350 primary care providers across our region to help design and develop our primary care engagement, leadership and development strategy.

We asked about their needs and opinions, their compliments and criticism. In the coming year you’ll see how we are responding, and how we are becoming the organisation that you want us to be, and that we need to be, to deliver better health in our community, every day in every way.

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