My Care Partners Archives | South Western Sydney PHN

24 September 2024

South Western Sydney Primary Health Network (SWSPHN) has commissioned EACH to provide the care coordination component of the My Care Partners program.

My Care Partners was launched in April 2021 as a joint initiative by SWSPHN and South Western Sydney Local Health District (SWSLHD) to assist general practices in supporting patients with chronic and complex health conditions to prevent hospitalisations.

As the new service provider, EACH will play a pivotal role in this program by supporting general practices in delivering coordinated team-based care to patients across the region.

SWSPHN Chief Executive Officer, Dr Keith McDonald PhD, said the new service provider was an important measure to continue to enhance the quality of care for patients in South Western Sydney suffering from chronic disease.

“A key goal of the partnership is to reduce potentially preventable hospitalisations,” he said.

“EACH will focus on boosting team-based care models and improving communication among care teams to ensure patients receive complete and organised care.

“EACH’s vision, mission and values align closely with the objectives of SWSPHN, making them an ideal partner for this program.”

With over 50 years of experience as a responsive, community-based organisation, EACH provides service to more than 65,000 customers from 58 locations across Australia.

As part of its service objectives, EACH will provide care coordination and care navigation services to at-risk patients and assist general practices in facilitating patient enrolment and engagement in My Care Partners activities.

The new service provider will improve communication among patient care team members and promote collaboration between different healthcare services to strengthen care models for at-risk patients.

To find out more about My Care Partners, visit our website

10 May 2023

The strong focus on primary care, with the tripling of the bulk billing incentive and investment in the health workforce to better meet the health needs of the Australians in the 21st century, were among the welcome features of Tuesday’s Federal Budget.

South Western Sydney Primary Health Network (SWSPHN) Acting Chief Executive Officer, Kristen Short, said there was little doubt primary care had been struggling in recent years, with fewer practices in a position to bulk bill, further highlighting the need for strong and ongoing funding commitment for the sector.

“The $3.5 billion committed to bulk billing incentives, $98.2 million for new Medicare rebates for patients who require consultations of longer than 60 minutes and $445.1 million to support team-based care in general practice, are welcome measures to support the revival and protection of a healthcare system which has served us well for decades,” she said.

Other investments of interest to primary care, in particular general practices in South Western Sydney include:

$358.5 million for Medicare Urgent Care Clinics
$143.9 million for after hours primary care
$91.5 million to improve mental health by addressing workforce shortages

Ms Short said SWSPHN had a particular focus on innovative projects like iRAD, the New to General Practice Nursing program and My Care Partners to build capacity and support our general practices in delivering accessible, effective and timely care to our community.

She noted investment in digital health ($951.2 million); increasing the number of nurses in primary care ($10.7 million); and increasing incentives for general practices to employ a range of health professionals to provide team-based primary care ($445.1 million) would support those projects which were already improving the health of our region.

“Primary care is the cornerstone of our healthcare system, and SWSPHN looks forward to continuing to work with and support primary care providers across our region on the projects, services and other activities funded in this budget.

“We particularly welcome the focus in the budget on multidisciplinary team care and voluntary patient enrolment and look forward to seeing how it complements our local medical neighbourhood model of care, My Care Partners, which has been working for the past two years to reduce avoidable hospital admissions and enhance care coordination for people with multiple chronic diseases.”

09 May 2023

Imagine your patient has had multiple organ transplants, suffers resulting chronic pain and is in cognitive decline. Your patient is taking a large number of complex medications under numerous specialists. Your patient’s situation is difficult, both medically and psychosocially.

What can you do to help them?

This scenario is likely not difficult for most GPs to imagine, given the role of primary carers in treating patients with chronic and complex health conditions – including diabetes, respiratory and cardiac disease – which lead to frequent presentations at hospital emergency departments.

A new program which adopts the ‘medical neighbourhood’ model of care has been developed specifically for this cohort of patients, to better co-ordinate and enhance their care and ultimately, to reduce unnecessary hospitalisations.

SWSPHN and South Western Sydney Local Health District (SWSLHD) have collaborated to develop My Care Partners, in consultation with community and healthcare providers. The program is unique to our region, and is tailored to suit the particular circumstances of individual practices.

Why was the program developed?

My Care Partners has been developed to achieve the Quadruple Aim for healthcare of:

improved population health
improved patient experience
improved provider experience
reduced healthcare expenditure

It recognises the necessity for GPs, specialists, hospitals and other clinicians to work in partnership to provide complete and coordinated care to patients with chronic and complex health concerns, to:

reduce potentially preventable hospitalisations
generate cost savings to the acute sector which are then redirected into primary care

How does the program work?

Participating GPs identify patients who may be eligible to participate in the 12-month program. These patients are referred to SWSPHN’s Care Enablers who assess the patient’s eligibility for the program.

Once enrolled, the patient has regular check-ins with members of the healthcare team which includes SWSLHD’s Care Coordinator, the GP, practice nurse and other members of the care team, such as allied health professionals and specialists.

The care team work together to identify other healthcare providers who may be beneficial to their patient’s care, other services their patient may be able to access, facilitate access to transport, and provide funding to support small home modifications and equipment.

How are patients referred and assessed for the program?

Patients identified as at risk of hospitalisation by GPs or via the SWSLHD Patient Flow Portal are referred to My Care Partners for assessment. The Care Enabler confirms the patient’s eligibility for the program, registers the patient, and alerts the patient’s GP and Care Coordinator to their enrolment in the program. The Care Coordinator undertakes a comprehensive health assessment and determines which of two intervention pathways are suitable for the patient.

The pathways include:

Care Coordination

Coordinates and connects patients with service providers to empower patients to better understand and manage their health, and to seek additional support when required from services including Meals on Wheels, community transport, counselling, podiatry, disability or aged care services.

Care Navigation

Facilitates access to services for the patient, their carers and family for a defined period of time, to improve the timeliness and appropriateness of care, reduce barriers to accessing care, reduce failures to follow up, and/or supports patients to navigate the health system.

What happens once patients are accepted into the program?

Once a patient is accepted into the My Care Partners program they will have a dedicated care team, led by their GP, to provide extra support to work towards better understanding and managing their condition.

The team communicates with each other regularly in the first three months of the program and all work with the patient to understand their goals and to support them in achieving those goals.

GPs arrange case conferences with the patient’s care team – and the patient if they would like to attend – at key points of the program to discuss how best to support patients with their condition and health goals.

How does SWSPHN support My Care Partners practices?

Practices receive support through a 12-week capacity building process which involves:

nominating practice representatives to participate in training
establishing processes to incorporate My Care Partners into their workflow
completing dedicated training on how to refer and enrol patients, and successfully complete program deliverables

As patients are enrolled, practices receive ongoing support from their My Care Partners Project Officer and Care Enablers to embed the program into their workflow and identify opportunities for improvement within their practice.

Communities of practice are also held to bring practices together to share experiences and knowledge, and to problem-solve to ensure the program is continually improving. A recent community of practice discussed case conferencing.

Who is participating in the program?

Sixty-five patients with chronic or complex conditions received care from five practices across Campbelltown, Camden and Wollondilly in Wave 1 of the My Care Partners program. SWSPHN is now recruiting practices for Wave 4 of the program, with the aim of 10 practices per wave.

In two years, it is hoped 60 general practices across South Western Sydney will be part of the program.

How have general practices and patients responded to the program?

Practices and patients have provided positive feedback about their experience of the My Care Partners program.

Patients have described the program as a positive experience, saying they felt cared for and listened to, while general practices have praised the support they receive from the My Care Partners team.

To continually improve My Care Partners, SWSPHN is engaging with expert evaluators to gain insight and feedback on the program.

If you have questions about My Care Partners download the information booklet (28-pages) or email SWSPHN – My Care Partners.

02 February 2022

My Care Partners is a 12-month program to help with the management of complex and chronic health conditions, such as diabetes, heart and lung disease.

Throughout the program you will have regular check-ins with members of a dedicated care team of health professionals to work towards achieving your health and wellness goals.

Participation in My Care Partners is voluntary. You are welcome to discuss the program with your General Practitioner (GP) as well as members of your family, carers or others who support you to consider how the program may be of benefit to you.

Once you have enrolled in the My Care Partners program, you will work closely with your GP, practice nurse and other members of your care team, which may include allied health professionals and specialists.

You will also work closely with a dedicated care enabler, a nurse who works within the Local Health District (LHD). Your care enabler will work closely with you, your GP and your care team to help you better understand and manage your health, and connect you with other services and support within your local community.

How My Care Partners works

You will have a dedicated care team, led by your GP, to provide extra support to help get your condition on track.
Your care team will communicate with each other regularly in the first six months of your program and work with you to understand your goals and help you achieve them.
Your GP will arrange case conferences with your care team at key points
of the program. A case conference provides your care team with an opportunity to talk to each other, and discuss how best to help you with your condition and health goals.
You are welcome to attend case conferences or your GP can let you know what was discussed.
Your health information will be shared securely between members of your care team and hospital.

If your GP is a My Care Partners partner and thinks you would benefit from taking part in the program, your GP will recommend this to you.

The My Care Partners Program has been designed by South Western Sydney PHN (SWSPHN) and South Western Sydney Local Health District (SWSLHD) to help patients improve their chronic or complex health conditions and avoid hospitalisation. The program was launched in April 2021 and is currently available at select medical practices in South Western Sydney.

30 November 2020

As those working in general practice know only too well, patients with complex health needs typically suffer from multiple chronic health conditions, functional limitations and unmet social needs.

With such complexity, a patient’s care can often be fragmented leading to concerns about the quality and safety of patient care, and increasing the risk of potentially-preventable hospitalisations.

SWSPHN’s new My Care Partners program aims to improve care co-ordination between the patients’ medical home, primary and community services and acute care, and ultimately improve outcomes for patients with complex and chronic conditions.

What is My Care Partners?

The My Care Partners program adopts a ‘medical neighbourhood’ model of care and has been co-designed by SWSPHN, the South Western Sydney Local Health District (SWSLHD), primary healthcare providers and community members. It involves a team-based approach to fulfil the individual’s required care needs. Team members include the patient and GP, as well as practice administration staff, practice nurses, specialists and allied health providers such as physiotherapists, podiatrists, dietitians, diabetes educators and psychologists. As an active member of the ‘medical neighbourhood’, practices will work collaboratively with other participating practices to improve the outcomes of a shared cohort of patients. As a result of shared care, the ‘medical neighbourhood’ can achieve ‘shared outcomes’ as well as ‘shared cost savings’ which are distributed among participating practices in the ‘neighbourhood’.

How does it work?

The program will provide participating practices with ongoing support to transform into a ‘patient centred medical home’. General practitioners will enrol patients with complex and chronic conditions who have been identified as at risk of frequent hospitalisations. Participating practices must make a number of commitments including:

Reviewing reports and working with enrolled patients and their care team to identify needs that can assist in reducing a patient’s risk of potentially preventable hospitalisations.
Providing protected time to allow for staff training and innovation.
Installing and enabling digital health applications to improve communication between providers and to track each patient’s journey.
Working with a SWSLHD Care Enabler and patient care teams to continue to provide team-based care to identify patients’ needs.

What is a SWSLHD Care Enabler?

The Care Enabler is a team member from the SWSLHD who will work with practices and My Care Partners patients to facilitate their care. The Care Enabler will form part of the patient’s care team to:

Assist patients in navigating the healthcare system.
Identify additional support for the patient.
Facilitate communication and appointments with the care team.
Assist in improving health literacy.

What are the benefits to the practice?

Some of the benefits include:

Staff trained in digital health readiness and enrolment readiness by the PHN team and Care Enabler team.
Opportunities for staff to suggest and work on quality improvement initiatives within the practice.
Learning opportunities for staff, including attending workshops and joining networking sessions.
Opportunities for staff to network with other My Care Partners practices and external providers in the ‘neighbourhood’ to improve communication and enhance relationships.
Team-based and patient-centred care.
Access to payments to set up as a My Care Partners practice, as well as ongoing patient enrolment and activity payments.
Access to ‘shared cost savings’ distributed across the ‘medical neighbourhood’ for practices who achieve patient outcomes.

What are the benefits to patients?

Some of the benefits include:

Improved outcomes for patients with complex and chronic conditions including reducing the risk of preventable hospitalisations
Improved patient experience by encouraging continuity of care and team-based care to reduce the risk of omission or duplication of services

When will the program begin?

SWSPHN has developed a general practice capacity building framework to support My Care Partners practices when implementation begins.

Recruitment has begun in the Campbelltown/Camden Hospital catchment – that is in Campbelltown, Camden and Wollondilly LGAs – before being rolled out across LGAs in the rest of the region. An Expression of Interest has been distributed to practices within the eligible LGAs. A maximum of 25 practices will be recruited for the first 12-month period. Patient enrolment will begin in 2021.

My Care Partners: Information for general practice and other health professionals