Care Partnership – Diabetes (CP-D) services in Far West NSW support improved patient access to clinical care, professional development for health practitioners, and health system improvements.
Patient access
The Far West Diabetes Service is integrated with the existing Planned Care for Better Health Model of Care within Far West Local Health District (FWLHD) Integrated Care.
Planned Care for Better Health (PCBH) aims to improve the patient's experience of care and keep patients healthier over the long term. It is focused on the needs of people who are at risk of hospitalisation or who would benefit from early intervention. The services provide care coordination, care navigation and health coaching to improve their experience and outcomes.
The program promotes self-management of health conditions and supports consumers in achieving their goals by providing education into their conditions and health, assistance coordinating their healthcare, and assistance in navigating the healthcare system in their community.
The FWLHD Diabetes service integrates with Planned Care for Better Health within Integrated Care to provide the above listed service, as well as providing access to specific services for Diabetes care.
The service offers access to a Diabetes Educator and Aboriginal Health Practitioner with multidisciplinary team access as required.
To refer a patient to the service:
- Email: FWLHD-PCBH@health.nsw.gov.au
- Phone: 1800 931 959
Due to the vast distances and remoteness of FWLHD, Community Engagement is a core part of our model of care. It is important to connect with our communities in a meaningful way to ensure that we are delivering place appropriate healthcare.
The Far West Diabetes Service will be visiting each of our communities regularly for early identification, community awareness and education and to ensure that we are meeting the needs of each individual community.
To find out where we will be next or get involved, please keep an eye on FWLHD's social media.
Far West Diabetes Service will use Patient Reported Measures (PRMs) as part of the approach to patient centred care, evaluation and monitoring of the program.
PRMs capture information via surveys, which ask patients about their healthcare experiences and the outcomes of their care and give clinicians an insight into the needs and expectations of patients at the point of care.
This feedback also helps to drive improvement across the NSW health system.
Reach out to FWLHD PRMs Project Manager, Kara Leonard via email.
Workforce Capability
The CP-D program supports a range of professional development services for health professionals in Far West and Western NSW who provide care for people living with type 2 diabetes.
CP-D supports local health professionals to pursue further professional development by facilitating access to grants that contribute to the cost of further study or professional development.
The program has supported more than 50 scholarships, bursaries or study leave grants for health practitioners in Western and Far West NSW including many who have completed or are pursuing Credentialled Diabetes Education qualifications. The participating health practitioners are on track to significantly increase these regions’ Credentialled Diabetes Educator workforce.
Eligible health practitioners can apply to the Health Workforce Scholarship Program for grants to support further study or professional development in managing type 2 diabetes. Grants are available for medical, nursing, midwifery, allied health, dental and Aboriginal and Torres Strait Islander health professionals who work in rural primary health settings.
Health practitioners who don’t work in primary care settings can write to westernT2DM@nswrdn.com.au to explore professional development opportunities or grants available to support their care for people living with type 2 diabetes.
The CP-D program works with partners to deliver upskilling events for health professionals who have a broad or specialised role providing care for people with type 2 diabetes in Far West and Western NSW.
Professional development events provided so far include a series of upskilling workshops for non-clinical health professionals; diabetes education sessions for clinicians pursuing CDE qualifications and Aboriginal health practitioners; and the Type 2 Diabetes ECHO series.
Information about relevant professional development events can be viewed on the Rural Health Training Calendar and searching for ‘diabetes’. You can also choose 'diabetes' as a professional interest in your Rural Health Pro profile to make sure you see diabetes related events. You can also email us for more information about upcoming events.
Project ECHO® (Extension for Community Healthcare Outcomes) sessions support peer virtual learning for health practitioners through case discussions. Two series of Type 2 Diabetes ECHO sessions have already been delivered and more are planned for GPs and primary health practitioners. These sessions support clinicians’ access to evidence-based, multidisciplinary information for their patients by discussing patient cases with a panel of experts and as well as peers. An introductory video explaining the Project ECHO® model is available here.
Project ECHO® sessions can offer:
- Increased knowledge and confidence in diabetes management
- Opportunity to earn CPD points
- Multidisciplinary advice for your patients
- Support from an engaged community of practice
- MBS case conferencing items for GPs presenting cases may be claimable
Information about upcoming ECHO sessions can be found on Western NSW PHN’s website here and the Rural Health Training Calendar.
Please write to echonetwork@wnswphn.org.au If you would like to participate in an upcoming ECHO session, request a topic or patent case study, or contribute on the panel.
The CP-D program team is actively looking to support health professionals in Western and Far West NSW to provide quality diabetes care for communities in the region. This include identifying and responding to:
- The needs of the region existing workforce;
- Workforce gaps and shortages; and
- Future workforce needs.
The program is exploring supports for these regions’ diabetes educator workforce, mentors of those in-training, and linking newly qualified diabetes educators to roles where they can utilise their skills.
If you would like to raise a workforce need or solution, contribute to governance or evaluation, or other opportunity, please write to westernT2DM@nswrdn.com.au.
System and Quality Improvement
CP-D takes a whole-of-system approach on access to care by supporting the provision of coordinated care systems through establishment and use of HealthPathways and INCA and other digital tools.
HealthPathways is a web-based portal for health practitioners that:
- has online clinical guidance and resources;
- is written by local GPs designed to be used in a consultation; and
- includes referral information for local services and specialists.
The diabetes pages on HealthPathways have been localised for the Far West and Western NSW regions and will continue to be updated.
Health practitioners can login or register to access localised HealthPathways or email HealthPathways for more information.
Inca is a secure web portal and mobile platform that allows you to create patient-centred Medicare-compliant GP Management Plans and Team Care Arrangements to:
- collaborate easily with internal and external care team members in real-time,
- reduce administrative burden on clinical staff with convenient, one-click electronic approvals of EPCs and care plans,
- allows patients to be active participants in their care - provide patients with online access to personalised care plans and chronic disease educational material,
- monitor patient measurements remotely.
To inquire about using Inca, please email our Digital Health Team.
Practices can receive customised practice reports every six months which shows how your patient population is utilising the broader health system including GP and hospital presentations. The Lumos program provides insights into patient pathways through the NSW health system by linking de-identified data from general practice with other health service data. Learn more about Lumos here.
In addition to practice population insights for practices, Lumos data will be utilised to support CP-D quality improvement and evaluation.
To inquire about using Lumos, please email our Digital Health Team.
Participating GP practices and ACCHSs have free access to the healthdirect Video Call platform to help support access to care for rural and remote communities. Powered by the COVIU system and administered by the WNSW PHN digital health team, the healthdirect Video Call platform is a secure, private platform and all calls are fully encrypted making it compliant for many clinical consultations.
- healthdirect Video Call offers a range of practical advantages to patients, doctors and clinics. It mimics the in-person appointment process via a virtual waiting room and virtual consulting room.
- Remote (indirect) examination by observation and with patient assistance.
- Reviews and multi-disciplinary consultations are more practical to conduct when clinicians and patients can attend remotely. Supports NSW Health Type 2 Diabetes Case Conferencing sessions.
- Can allow for multiple guests to join calls via email link invites.
To register a healthdirect Video Call account, please email our Digital Health Team.
Far West of Centre podcast
The FWLHD's Integrated Care Services has taken to the airwaves with a podcast to showcase the services on offer and introduce their team to the community. This has been a successful tool in promoting our services and engaging with members of our community.
Search 'Far West of Centre' on Spotify, Apple Podcasts, Google Podcasts, Castbox, Amazon Music, RadioPublic, iHeartRadio and Overcast today!
The Care Partnership – Diabetes program is a collaboration between the Western NSW Local Health District, the Far West Local Health District, the Western NSW Primary Health Network and Rural Doctors Network.
