08 April 2026

QIPC newsletter - Quality improvement in primary care

Our ageing population
Potentially preventable hospitalisation rates
How an ageing population affects providers
How GPACI can help your practice
Introducing POLAR Puffin
When QI and GPACI join forces
Walkthroughs and resources
Helpful tips for health professionals
Additional resources

 

“Every person living in a residential aged care home has the right to receive safe, timely, high-quality care.”
– Final Report, Royal Commission into Ages Care Quality and Safety (Royal Commission)

 

South Western Sydney and its ageing population

The World Health Organisation 2025 highlighted advances in social, economic and medical developments have resulted in longer life expectancies and lower mortality rates – ‘one of our most remarkable collective achievements’.

More than one million people reside in South Western Sydney, and it remains one of the fastest growing regions in NSW. Our rapid population growth is driven mostly by greenfield developments and urban intensification.

In response to our expanding community SWSPHN and the South Western Sydney Local Health District collaborated to create an in-depth health needs assessment. This in-depth analysis of the population prepares our community to be informed for future health planning and be able to successfully meet our region’s key health needs.

One of the key areas identified in this analysis was our rapidly growing and ageing population. The total population of people aged 65 years or older is expected to increase significantly between 2016 and 2031, from 127,000 to 221,000 (a total increase of 74 per cent). Additionally, those aged 85 years or older are expected to increase by 92 per cent – with an additional 14,660 people.

Bar chart showing projected population growth across seven local government areas in South Western Sydney from 2016 to 2031. Liverpool has the highest population, increasing from just over 200,000 in 2016 to about 301,110 in 2031. Bankstown grows to around 247,220, Fairfield to 221,000, and Campbelltown to 214,140. Camden shows strong growth from a lower base, reaching 185,570 by 2031. Wollondilly increases to 64,460, while Wingecarribee remains the smallest at 51,200. Overall, all areas show steady population growth over time.

Figure 1 – Projected population growth in South Western Sydney by LGA, 2016-2031

South West Sydney – Our Health in depth

Current data predicts Camden and Liverpool local government areas (LGAs) are taking the lead in population growth rates. It is predicted by 2031 Camden will have the largest population growth by more than double, with increases from 81,000 to 186,000 people.

Bar chart showing projected population growth percentages from 2016 to 2031 across South Western Sydney local government areas compared with the NSW average of 21.3 percent. Camden has the highest growth at 129.5 percent. Liverpool follows at 40.7 percent. Wollondilly is 31.0 percent and Campbelltown is 30.4 percent. Bankstown is close to the NSW average at 21.4 percent. Wingecarribee has lower growth at 7.8 percent, and Fairfield is the lowest at 7.2 percent. Overall, most areas are expected to grow faster than the NSW average, especially Camden.

Figure 2 – Projected population growth (per cent) in South Western Sydney LGAs and NSW, 2016-2031

South West Sydney – Our Health in Brief

 

South Western Sydney has the highest potentially preventable hospitalisation rates in NSW

Potentially preventable hospitalisations (PPH) are determined by hospitalisations which may have been avoided with either preventative care or early disease management. This doesn’t mean the hospital admission wasn’t necessary at the time. It may have been prevented with the use of primary care services which were timely and appropriate.

Recent PPH data confirmed chronic, vaccine preventable and acute conditions were higher for South Western Sydney residents compared to the rest of the state, as seen in Figure 3. The most common reasons for PPH included but aren’t limited to; cellulitis, urinary tract infections, ear, nose and throat infections, and congestive heart failure.

Table comparing rates of potentially preventable hospitalisations per 100,000 population between NSW and South Western Sydney. South Western Sydney has higher rates across all categories. Chronic conditions are 1,046.6 in South Western Sydney compared with 963.4 in NSW. Vaccine preventable conditions are 305.5 compared with 181.7. Acute conditions are 1,161.1 compared with 1,125.8. The total rate is 2,476.4 in South Western Sydney and 2,248.4 in NSW.

Figure 3 – Potentially preventable hospitalisations, rate per 100,000 population NSW and South Western Sydney 2016-17 

 

How will an ageing population affect primary healthcare providers?

Primary healthcare providers play an essential role in caring for older people in the community, as general practices are often a patient’s first point of contact. Our primary healthcare providers’ contribution in early detection and treatment of chronic conditions is crucial in minimising the impact on both the healthcare systems and individual patients’ lives.

The Australian Institute of Health and Welfare recognised yearly GP service attendance rates increased from 3.8 to 6.2 visits per person in 2025.

Despite the expected demographic shift towards an ageing and rapidly growing population, the World Health Organisation 2024 raised the concern “care and support systems across the world are not yet prepared to meet the needs of older people”.

With an ageing population, chronic diseases and multiple comorbidities are likely to become more prevalent. Furthermore, the demand for permanent residential aged care and the number of people requiring this level of care is expected to almost double in 15 years from 5,947 to 10,894 people by 2031.

Bar chart showing the projected number of people requiring or living in residential aged care in South Western Sydney by local government area and gender from 2016 to 2031. Numbers increase steadily over time for both females and males in all areas, with females consistently higher than males.

Fairfield has the highest numbers, rising to around 1,400 females and 900 males by 2031. Liverpool and Bankstown also show high demand, with female numbers reaching about 1,300 to 1,400 and males around 800 to 900. Campbelltown shows moderate growth, with females reaching around 1,100 and males about 650.

Camden, Wingecarribee, and Wollondilly have lower overall numbers but still show steady increases. By 2031, Camden reaches roughly 800 females and 450 males, Wingecarribee about 650 females and 350 males, and Wollondilly remains the lowest at around 350 females and 250 males.Figure 4 – Number of persons requiring or in residential aged care for South Western Sydney by LGAs and gender, 2016-2031 

 

What is GPACI and how can my practice get involved?

The General Practice in Aged Care Incentive (GPACI) was introduced in July 2024. GPACI aims to support continuity of care and reduce avoidable hospitalisations for older people living in residential aged care homes (RACH), through proactive visits and chronic disease management.

The introduction of GPACI incentives was in response to the Royal Commission into Quality and Safety in Aged Care and Strengthening Medicare, both of which identified the need to shift our focus towards our rapidly growing and ageing population.

For more information on eligibility and servicing requirements for GPACI – please refer to the General Practice in Aged Care Incentive program guidelines.

 

Introducing POLAR Puffin: less GPACI administration, more time for what matters

The Early Insights from the General Practice in Aged Care Incentive reported more than $14.3 million was distributed to general practices and providers with a strong initial uptake in GPACI. However, a common barrier identified was the complex and administrative workload in monitoring service requirements for ongoing participation – it was often described as overly burdensome through GP and practice surveys.

To overcome the common barrier of a high administrative workload in GPACI, Western Victoria PHN and Outcome Health worked together to create a solution – a new POLAR report called Puffin.

Puffin has been tailored to be used by GPs and practices to assist with visualising and meeting their GPACI quarterly reporting requirements, as well as optimising time spent on patient care. The new Puffin report was trialled with a small group of general practices in Western Victoria, with positive feedback overall. Puffin was successful in reducing the amount of time spent tracking GPACI servicing requirements and reducing errors previously made in manual tracking.

Puffin is readily available at no extra cost to all current users of POLAR. It is currently integrated with Best Practice, Medical Director and Zed Med users.

If you want to know more about Puffin or are thinking about getting involved in GPACI, please contact your Practice Advancement Officer (PAO)/Practice Support Officer (PSO).

Lean more about Puffin

 

How can Quality Improvement and GPACI join forces?

Quality Improvement (QI) plays a pivotal role in driving practice-based decisions to make changes, based on practice specific demographics and needs. POLAR Puffin is a user-friendly data extraction and analysis tool which can be utilised to support both QI-based activities and meet GPACI quarterly servicing requirements.

Some ways POLAR Puffin can be incorporated into your practice’s QI activities include:

  • identify GPACI-registered patients in PRODA and update Puffin patient list accordingly (when first using Puffin)
  • identify GPACI-registered patients who have not yet met the quarterly requirements for eligible regular services
  • identify GPACI-registered patients who have not yet met care planning requirements over the 12-month period
  • identify GPACI-registered patients eligible for a vaccination (COVID, shingles, influenza)
  • track improvements in GPACI service delivery each quarter – by using the Model for Improvement, compare baseline and current data
  • collaborate with SWSPHN in quarterly QI meetings for a team-based QI approach and assistance in using POLAR Puffin or to further improve practice data and service delivery

Helpful resources for health professionals:

Puffin Introduction | Western Victoria PHN
GPACI: Patient Information Booklet

 

SWSPHN walkthroughs and resources

SWSPHN has various resources to assist your practice with QI activities and introducing the use of the new POLAR Puffin report within your practice. If you are unsure how to access POLAR or need help with initial use of Puffin, contact your Clinical and Quality Improvement (CQI) Officer or your PAO/PSO for more information.

Model for Improvement (MFI):

Model for Improvement Template
Model for Improvement Walkthrough
Sample MFI – GPACI Care Planning
Sample MFI – GPACI COVID Vaccine Eligibility

POLAR Puffin Walkthroughs:

POLAR Puffin Walkthrough – Patient Management
POLAR Puffin Walkthrough – Applying Filter

 

Helpful tips for health professionals participating in QI

Maintain accurate data in patient files – POLAR extracts data from the practice’s clinical information software. POLAR does not obtain data from AIR, My Health Record or PRODA.

Using POLAR Puffin for the first time?

When first using Puffin, it is recommended you extract an accurate list of GPACI-registered patients from PRODA

Using the GPACI-registered patient list from PRODA, update your Puffin patient list accordingly – adding/removing patients as appropriate

Private bookmark function

The private bookmark function in POLAR allows users to save searches created with specific filters for future reference.

 

References and additional resources

Introducing POLAR Puffin | South Western Sydney PHN
South West Sydney: Our Health in depth
South West Sydney: Our Health in brief
Final Report – Care, Dignity and Respect: Volume 1 | Royal Commission into Aged Care Quality and Safety
Strengthening Medicare | Department of Health, Disability and Ageing
Early Insights from the General Practice in Aged Care Incentive | Department of Health, Disability and Ageing
Ageing: Global population | World Health Organization
WHO calls for urgent transformation of care and support systems for older people | World Health Organization
General practice, allied health and other primary care services | Australian Institute of Health and Welfare
General Practice in Aged Care Incentive program guidelines | Department of Health, Disability and Ageing

If you wish to find out more POLAR Puffin or SWSPHN’s QIPC program, please email cqisupport@swsphn.com.au  or visit our website Quality Improvement in Primary Care.

08 December 2025

Rising concerns in childhood vaccinate rates

Why are vaccination coverage rates declining?

How does misinformation impact vaccination rates?

Role of primary healthcare providers in improving vaccination rates

How can Quality Improvement (QI) support your practice?

How to identify missed childhood vaccinations using POLAR

SWSPHN walkthroughs and resources

Helpful tips for health professionals participating in QI

References/resources

 

“We all need to be reminded vaccine-preventable viruses or bacteria can and do cause serious illness and even death, and they haven’t gone away”
– Dr Matthew Gray

Rising concerns in childhood vaccination rates

Previously, Australia maintained high success rates of vaccination coverage for children.

However, the National Centre for Immunisation Research and Surveillance (NCIRS) identified there are rising concerns and continual declines in childhood vaccination rates since the COVID-19 pandemic.

Recent data showed current childhood vaccination rates are in fact lower than they were pre-pandemic, highlighting the importance of identifying barriers to vaccine access and acceptance.

Vaccinations are the most simple and effective way of protecting yourself and your community against vaccine-preventable diseases.

Immunisation programs prevent approximately 2.5 million deaths every year world-wide, according to the Australian Government.

Recent data showed vaccination rates were lower for two-year-olds than those aged one and five years.

The Department of Health, Disability and Ageing identified that across highly populated suburbs (Statistical Area – Level 3 criteria) in South Western Sydney (SWS), Bankstown had the lowest vaccination coverage for children aged one year (89.3 per cent), two years (86.3 per cent) and five years (92.9 per cent).

Figure 1 – Childhood vaccination rates July 2024 – June 2025
Figure 1 – Childhood vaccination rates July 2024 – June 2025


Source: SWSPHN 2025-2028 Health Needs Assessment

 

Why are vaccination coverage rates declining?

In 2019, the World Health Organisation (WHO) placed vaccine hesitancy in the top 10 threats to global health.

The National Vaccination Insights Project 2025 performed a recent study to identify childhood vaccination barriers for Australian parents which included:

  • poor access to immunisation services
  • low confidence in vaccination efficacy
  • misinformation based on myths surrounding vaccination coverage and its importance
  • mistrust in healthcare professionals providing information
  • social influences

Vaccination barrier Parents with unvaccinated children (%) Parents with partially vaccinated children (%) Parents with up-to-date children (%) All parents (%)
Do not intend to give child all recommended vaccines 48.8 10.8 4.8 5.7
Do not believe vaccines are safe for child 47.9 17.7 4.8 6
Would not feel guilty if did not vaccinate child and child got a VPD 46.7 16.0 7.1 8.1
Do not believe vaccinating child helps protect others in the community 39.7 14.0 3.9 4.9
Do not believe vaccines are effective for preventing diseases 39.8 14.3 4.4 5.3
Vaccinating on time is not my responsibility 12.8 10.4 3.9 4.3
Feel distressed when thinking about vaccinating child 65.4 55.4 60.3 60.2
Do not trust information received about vaccines from child’s doctor or nurse 43.7 16.8 5.4 6.4
People close do not support vaccination 21.8 11.5 5.5 6
Child’s doctor or nurse cannot answer questions about vaccination 20.2 10.8 4.4 4.9
Do not prioritise child’s vaccination appointment over other things 47.6 23.9 6.9 8.2
Not easy to travel to child’s vaccination appointment 12.1 8.9 4.9 5.2
Cannot afford costs associated with vaccinating child 16.5 20.5 10.4 11
Not easy to get an appointment when child’s vaccination is due 14.2 24.8 8.5 9.3
Cannot discuss vaccination in preferred language with child’s doctor or nurse 10.5 11.0 6.2 6.5

 

Access | Practical barrier

 

Acceptance | Thinking-feeling barrier

 

Acceptance | Social influence barrier

Source: Childhood vaccination barriers in Australia and strategies to address them, October 2025

 

How does misinformation impact vaccination rates?

The term herd immunity refers to slowing or stopping the transmission of a disease within a community as a result of high levels of vaccination coverage.

A common myth about herd immunity is, if most of the community is vaccinated, an unvaccinated person will be protected by everyone else.

The danger in this misconception is if more people in the community adopt this belief, vaccination rates will continue to decline.

Australian immunisation coverage rates for five-year-olds stood at 95 per cent in 2020 but have since declined to 93.27 per cent in 2025.

The Australian Government has established 95 per cent as the minimum immunisation rate required to achieve herd immunity for many vaccine-preventable diseases.

The overall decrease of vaccination rates in the community poses a risk for outbreaks of previously eliminated vaccine-preventable diseases in Australia.

Vaccinations prevent deaths, serious illness and minimise transmission rates.

Figure 2 - Annual Global Immunisation Coverage Report 2024 – Summary | NCIRS
Figure 2 – Annual Global Immunisation Coverage Report 2024 – Summary | NCIRS

Source: Annual Global Immunisation Coverage Report 2024 – Summary | NCIRS

 

There is no singular solution or approach for vaccine hesitancy as the magnitude of negative beliefs, myths and mistrust must be addressed individually for each patient and/or parent.

SWSPHN has recently launched an Immunisation Hero campaign to support general practices in promoting immunisation uptake and boosting vaccination awareness within the community.

For more information or resources, please visit our website: Immunisation Hero

 

Role of primary healthcare providers in improving vaccination rates

Primary healthcare providers play a crucial role in increasing vaccination coverage, as they are the key providers in administering vaccinations and re-shaping public opinions through education.

Primary healthcare providers could:

  • improve their own confidence in providing information on immunisations to their community
  • promote vaccination in the community through displaying educational posters, brochures and/or pamphlets in their practice to become a local immunisation hero!
  • allow time for discussions surrounding vaccinations and addressing individual concerns
  • participate in quality improvement activities to increase vaccination coverage within the community
  • utilise effective recall and reminder procedures within the practice
  • maintain up-to-date patient files

Helpful resources for health professionals:

How to talk about vaccines | WHO

Trusted immunisation resources for general practice | SWSPHN

CPD events calendar for primary healthcare in South Western Sydney | SWSPHN

 

How can QI support your practice?

Quality Improvement plays a pivotal role in driving practice-based decisions to make changes, based on current evidence.

POLAR is a user-friendly data extraction and analysis tool which can be used to support QI-based activities in your practice.

Ways POLAR can assist with QI:

  • create a patient list within POLAR that identifies patients eligible for a specific immunisation – you can tailor your report to meet practice needs or a specific demographic
  • utilise the extracted patient list to audit patient files and identify any gaps in clinical data
  • utilise Walrus alongside your clinical information software system to further identify missing data within the practice. For more information on Walrus, refer to the POLAR Walrus Tool Guide
    track improvements in practice data quarterly in conjunction with Models for Improvement to compare baseline and current data
  • collaborate with SWSPHN in quarterly QI meetings for a team-based QI approach and assistance in using POLAR or how to further improve practice data

 

How to identify missed childhood vaccinations using POLAR

Due to a national decrease in childhood vaccination coverage, SWSPHN has created a POLAR walkthrough to help practices identify potentially missed childhood vaccinations.

Specific filters applied can be tailored to your practice and demographic needs.

POLAR Walkthrough – Childhood Vaccination Eligibility

 

SWSPHN walkthroughs and resources

SWSPHN has various resources to assist your practice with QI activities.

If you are unsure how to access POLAR or need help obtaining data, contact your CQI officer or your PAO/PSO for more information.

Model for Improvement Template

POLAR Walkthrough – Adult Prevenar 13 Eligibility

POLAR Walkthrough – Shingrix Vaccine Eligibility

 

Helpful tips for health professionals participating in QI

Maintain accurate data in patient files, POLAR extracts data from the practice’s clinical information software.

POLAR does not obtain data from AIR, My Health Record or PRODA.

If immunisations were administered elsewhere, update the patient file to reflect this in conjunction with the patient’s AIR immunisation history.

SWSPHN has created a sample, editable Model for Improvement (MFI) to help practices implement processes to regularly update immunisation history using AIR:

Sample MFI – Maintain Accurate Immunisation Records

 

Clinical information software walkthroughs to utilise AIR to maintain up to date patient records:

MedicalDirector Walkthrough – Update Immunisation History via AIR

Best Practice Walkthrough – Update Immunisation History via AIR

 

Private bookmark function:

The private bookmark function in POLAR allows users to save searches created with specific filters for future reference.

POLAR Walkthrough – How to create a private bookmark

 

References/resources

Immunisation programs | NSW Health

New research urges coordinated action to reverse Australia’s declining childhood vaccination rates | NCIRS

Childhood vaccination barriers in Australia and strategies to address them | National Vaccination Insights Project

About immunisation | Department of Health, Disability and Ageing

Immunisation Hero | SWSPHN

 

If you wish to find out more about vaccinations in POLAR or SWSPHN’s QIPC program, please email cqisupport@swsphn.com.au or visit our website Quality Improvement in Primary Care. 

25 November 2025

The way practices in South Western Sydney request POLAR support has changed. This page details the new process for seeking support and why the procedure has changed.

 

Key points

  • Practices no longer contact South Western Sydney PHN to request support for POLAR.
  • Practices must now contact the software supplier – Outcome Health – by navigating to the Support menu in POLAR Explorer or by email to servicedesk@outcomehealth.org.au

When the following issues occur, lodge a support request through the Support menu in POLAR or email a support request to servicedesk@outcomehealth.org.au. A representative from the polar SOFTWARE SUPPLIER – Outcome Health will be in touch.

Request require technical support for:

  • login, data sync errors or system bugs issues
  • platform-specific troubleshooting
  • system performance and functionality problems
  •  installation or uninstallation of Hummingbird/POLAR requests

 

POLAR Support menu location - select Contact Us to request support.

 

What to expect

Support is provided by Outcome Health between 9-5pm, Monday to Friday (AEST), excluding public holidays.

Expect a response to your enquiry within 24 hours but due to the variability in support tickets, Outcome Health are unable to guarantee a resolution time.

 

When to contact SWSPHN’s Digital Health team

SWSPHN uses Outcome Health’s products but does not maintain them. We will continue to provide the following functions:

  • create new user accounts
  • delete user accounts
  • correct malformed UTF-8 data (item 6 errors)
  • change the practice name (excluding ABN, server, CIS or other technical details)
  • guide practices on how to lodge an enquiry
  •  encourage practices to utilise POLAR frequently to assist with quality improvement activities

How SWSPHN’s Service Support team can help

Practices can reach out to their Practice Advancement officers (PAO), Practice Support officers (PSO) or their Clinical and Quality Improvement officers (CQI) for the same above functions.

 

Why the process has changed

This change reflects Outcome Health’s new licensing terms – which are compulsory for all licensees.

Outcome Health will monitor Hummingbird daily (or every second day) and will contact your practice directly if issues are detected.

While SWSPHN no longer proactively monitors POLAR dashboards or advises practices of system anomalies, we will be assisting Outcome Health as needed to resolve problems.

SWSPHN will receive a monthly report from Outcome Health and will monitor and evaluate the impacts of this new process. We will utilise this information to identify issues that may impact PIP QI submissions.

We appreciate your support as we transition to this new model.

These changes aim to streamline technical support through Outcome Health while allowing SWSPHN to focus on guidance, usage and escalation where needed.

29 September 2025

Cardiovascular disease (CVD) is one of the major health concerns in Australia; it remains the key cause of death and morbidity nationwide. According to the Heart Research Institute, CVD is contributing to more than 1.2 million hospitalisations each year and leads to long-term complications.
Source: Heart Research Institute, 2024.

 

This 2024 cardiovascular disease infographic from Heart Research Institute shows in Australia there is an average 57,000 heart attacks each year, a person dies from CVD every 12-minutes, over 4 million Australian have CVD - which is one in six people, and the cost of CVD on the Australian health system is more than $12.7 billion dollars annually. Around 42,700 liver are claimed due to CVD each year.

Primary prevention in general practice plays a significant role in early identification and management of modifiable CVD risk factors such as blood pressure, cholesterol and smoking.
The National Preventive Health Strategy 2021-2030 and the RACGP Guidelines strongly recommend the use of absolute CVD risk assessments in the primary healthcare setting, which is also embedded as one of the 10 PIP QI measures.

National Preventive Health Strategy 2021-2030
RACGP Guidelines
10 PIP QI measures

 

Understanding and addressing modifiable cardiovascular risk factors

Many of the risk factors contributing to CVD are modifiable, meaning they can be influenced through lifestyle changes, medical intervention or both. Addressing these factors not only reduces the risk of CVD but contributes to improved outcomes in diabetes, kidney disease and mental health.
Key modifiable risk factors for CVD:

  • tobacco smoking
  • obesity (BMI)
  • physical inactivity
  • hypertension
  • hyperlipidaemia
  • unhealthy diet
  • excessive alcohol consumption
  • diabetes and impaired glucose regulation
  • psychosocial stress

Among these, body mass index (BMI) and smoking status are particularly significant, as they directly contribute to the calculation of an individual’s absolute CVD risk.

Recording BMI is essential in identifying overweight and obesity, both of which are associated with increased blood pressure, adverse lipid profiles, insulin resistance and ultimately a higher risk of cardiovascular events. According to the Australian Bureau of Statistics, adults with elevated waist circumference have a five per cent higher risk of developing CVD.

Smoking remains one of the highly significant independent risk factors for cardiovascular disease. Current smokers are estimated to have three times the cardiovascular mortality risk compared to non-smokers.

Despite this, documentation remains suboptimal. The AIHW’s 2021–22 Practice Incentive Program – Quality Improvement (PIP QI) report revealed only 49.8 per cent of eligible patients aged 45 to 74 years (without known CVD) had sufficient data recorded to calculate an absolute CVD risk score. In South Western Sydney, POLAR data shows only 43 per cent of eligible patients have a documented CVD risk score.

Further data from AIHW (2014) highlights:

  • Only 22.7 per cent of patients aged 15 years and older had a recorded BMI
  • Only 64.7 per cent had a recorded smoking status within the previous 12 months

These figures demonstrate clear opportunities for improvement in routine risk assessment and documentation.

AIHW 2021–22 Practice Incentive Program – Quality Improvement (PIP QI) report

POLAR Explorer

 

How your practice can contribute

As a key part of the primary care system, general practice teams can play a pivotal role in CVD prevention by using tools such as POLAR to identify patients with incomplete risk factor data.

To ensure accurate CVD risk calculation:

  • BMI (height and weight) should be updated annually, as per PIP QI Measures 2023-24
  • smoking status, including confirming known non-smokers, should be reviewed at least annually, and updated immediately if a patient’s smoking behaviour changes

Accurate and up-to-date documentation:

  • enables the calculation of absolute CVD risk
  • facilitates the delivery of brief lifestyle interventions
  • supports timely referral to appropriate services such as smoking cessation programs or the HEAL (Healthy Eating Activity and Lifestyle) program

Australian CVD risk calculator
HEAL (Healthy Eating Activity and Lifestyle)

 

How POLAR can support better CVD risk assessment

POLAR offers practical tools to enhance CVD risk assessment workflows:

  • identify patients eligible for CVD risk assessment
  • use Walrus or filters in reports to identify missing data (e.g. BP, cholesterol, smoking status)
  • track improvements over time with baseline comparisons and quarterly monitoring
  • collaborate with PHN staff via quarterly Model for improvement (MFI) sessions for a team-based QI approach
  • collaborate with PHN team to apply a private bookmark for streamlined and quick access to relevant POLAR reports.

Visit POLAR Knowledge Base to learn about Walrus

Download the QIPC Model for improvement template

Download the Private Bookmark POLAR Walkthrough for instructions

 


There are a couple of reports which could assist practices in improving CVD risk data:

QIPC Clinic report – CVD module (At Risk cohort)

The CVD module in the report helps visualise patients’ risk documentation status for a certain time period and opportunities for improvement.

This screenshot of the POLAR interface highlights how to view patients' risk status.

 

PIP QI report

This report supports practices to meet and track progress against PIP QI measures, such as CVD risk factors.

This screenshot of the POLAR interface shows how to view a summary of patients at risk of CVD.

MBS items relevant to CVD risk – Heart Health Check

MBS Item Description Eligibility Frequency Fee & rebate
699 Heart Health Check by a GP: ≥ 20 minute consultation including history, BP, cholesterol, risk plan Patients aged ≥ 45 years, or ≥ 30 years for First Nations people Once per patient every 12 months ~$84.90 (GP, pre 2019); updated to $80.10 ↓, full rebate
(Health.gov.au, Heart Foundation)
177 Heart Health Check by a non-specialist medical practitioner (other than a GP) Same as Item 699 broadens eligibility to non-GP practitioners in primary care settings Same rule as above Lower fee (~$64.10), full rebate (Heart Foundation)

 

Notes:
Items can be claimed once per patient in a 12-month period and cannot be claimed if the patient has had other health assessments (e.g. items 701, 703, 705, 707, or 715) in that time.
Heart Foundation, NPS Australia

From 1 July 2023, the previous restriction preventing co-claiming with a First Nations health assessment has been removed, supporting more flexible care for First Nations patients.
MBS Online

 


 

How our PHN can assist you

  • access to targeted training on CVD risk assessment and POLAR usage
  • organise quarterly MFI meetings and six-week check-ins for Tier 3 practices
  • offer Heart Health toolkit with step-by-step POLAR walkthroughs and editable sample MFIs
  • assist practices to identify data gaps and track progress in CVD risk management using POLAR

 

Private bookmark

The Private Bookmark Function in POLAR allows the user to save searches of specific patient cohorts by creating a bookmark. The user can create these bookmarks by clicking the tab at the top right-hand corner of the page.

 

Useful resources

AIHW – Burden of CVD in Australia
Heart Foundation – Heart Health Checks
CVD Check Tool
CVD Guidelines for Health Professionals
NPS MedicineWise – Absolute CVD Risk in Practice
Relevant newsletter: How practices tackle cardiovascular disease using POLAR

 

If you wish to find out more about CVD in POLAR or SWSPHN’s QIPC program, please email cqisupport@swsphn.com.au or go to Quality Improvement in Primary Care.

13 June 2025

This QIPC newsletter article outlines practical steps general practices can take to prepare for the changes to chronic disease management MBS items coming into effect from 1 July 2025. It includes a summary of the new items, the role of MyMedicare registration, and tips for updating workflows, improving data quality, and supporting continuity of care. It also highlights tools and resources available through SWSPHN’s QIPC program to help practices adapt smoothly.

Key points

  • New MBS items begin 1 July 2025 – GPMPs and TCAs will be replaced with the GP Chronic Condition Management Plan (GPCCMP).
  • Existing item numbers will be removed – Item numbers for developing and reviewing GPMPs and TCAs will cease.
  • MyMedicare registration will matter more – Access to GPCCMP and new telehealth items will be linked to a patient’s registered practice.
  • Equal fees for plan preparation and reviews – Designed to encourage regular chronic condition reviews.
  • Telehealth access expanded – New item numbers for video consultations will be introduced.
  • Support available from SWSPHN – Tools and resources from the QIPC program can help practices prepare.
  • Checklist and POLAR tools provided – Use POLAR, clinical software tips and the practice checklist to get ready.

 

Changes to chronic disease management aim to:

  • simplify, streamline and modernise the arrangements for healthcare professionals and patients
  • promote continuity of care
  • encourage the regular review of chronic disease management plans
  • support communication between a patient’s multidisciplinary care team
  • ensure existing patients can continue to access the care they need

As part of the changes, the current GP management plans (GPMPs) and team care arrangements (TCAs) will be replaced with a single GP chronic condition management plan (GPCCMP). The existing MBS items for developing and reviewing GPMPs and TCAs will cease, and new MBS items for the GPCCMP will be introduced.

GPCCMPs are for patients with one or more chronic medical conditions who would benefit from a structured approach to their care. It is up to the GP’s clinical judgment to determine if their patient would benefit from a GPCCMP.

From 1 July 2025 the following MBS items will cease:

  • GP management plans: 229, 721, 92024, 92055
  • Team care arrangements: 230,723, 92025, 92056
  • Reviews: 233, 732, 92028, 92059

The changes will encourage regular chronic condition management plan reviews by equalising the fees for developing and reviewing GPCCMPs. The proposed new MBS item numbers are as follows:

Name if item GP item number Prescribed medical
practitioner item number
Prepare a GP chronic condition management plan – face-to-face 965 392
Prepare a GP chronic condition management plan – video 92029 92060
Review a GP chronic condition management plan – face-to-face 967 393
Review a GP chronic condition management plan – video 92030 92061

More information about the upcoming changes to MBS Chronic Disease Management can be found at MBS Online.

 

Preparing for the proposed changes – MyMedicare registration

MyMedicare logo

MyMedicare is a voluntary patient registration model available to all patients, practices and primary care providers who meet eligibility requirements. It aims to formalise the relationship between patients, their general practice, GP and primary care teams.

 

aged care resident give the thumbs up while being consulted by her GPWhy do we need MyMedicare registration?

Evidence shows seeing the same GP and healthcare team regularly leads to better health outcomes. MyMedicare registration enables a practice to access more information about their regular patients, making it easier to tailor services to fit the patient’s needs.

To support continuity of care for people with chronic and complex conditions, patients registered through MyMedicare will be required to access the GPCCMP and review items through the practice where they are registered. Patients who are not registered in MyMedicare may still access the services through their usual GP.

New telehealth items will be linked to MyMedicare registration, including:

  • longer MBS-funded phone calls (Level C and D) with the patient’s usual practice
  • triple bulk-billing incentives for longer MBS telehealth consultations (Levels C, D and E) for children under 16 years, pensioners and concession card holders.

Find out more – General Practice MyMedicare registration

Find out more – Patient MyMedicare registration

Find out more – Upcoming changes to the MBS Chronic Disease Management Framework

eLearning: MyMedicare – Health Professional Education Resources

 

To help your practice prepare for the transition to chronic conditions management (CCM), start by implementing small, manageable changes. Focus on raising awareness among your team about MyMedicare and the updates to CCM. Encourage your team to explore their roles in both MyMedicare and CCM.

 

Examples of QIPC resources.

QIPC and CCM

The SWSPHN Quality Improvement in Primary Care (QIPC) program has three main aims:

  1. improve data quality
  2. utilise practice data to improve patient care
  3. identify potential business revenue for the practice

In line with these three aims, a quality improvement (QI) focus area often chosen by practices is identifying patients with a chronic disease who are potentially eligible for care plans.

In preparation for the proposed CCM changes, practices can ensure their current patients with a chronic disease are registered with MyMedicare. The SWSPHN Clinical and Quality Improvement (CQI) team has prepared resources to assist practices with this:

POLAR walkthrough – You can check how many of your patients with a chronic disease are registered/not registered for MyMedicare

MFI – A sample QI activity to register current chronic disease management patients with MyMedicare

Best Practice and MedicalDirector Clinical software guides – Where to document MyMedicare registration in the patient file to enable POLAR to pick up

 

Helpful tips for GPs, managers and nurses

Private bookmark:

The Private Bookmark Function in POLAR allows the user to save searches of specific patient cohorts by creating a bookmark. The user can create these bookmarks by clicking the tab at the top right-hand corner of the page.

Download Private Bookmark Walkthrough

 

Correct documentation:

For POLAR to obtain precise and reliable data, every item should be documented correctly in the patient’s file. To assist clinicians and practice staff in documenting care items in the appropriate location in their clinic’s medical software, data mapping is available via the Help menu.

Screen capture showing where to find data mapping help in POLAR. Go to the Help menu, then select Data mapping for this page.

Practice checklist

To help your practice get ready, we’ve put together a simple Practice Checklist you can utilise and ensure a smooth transition. It outlines some steps to align your current chronic disease management workflow with the updated MBS items and highlights practice actions your team can take now to stay ahead.

Preparing Your Practice for Chronic Condition Management Reform Checklist

To find out more about SWSPHN’s QIPC program, please email cqisupport@swsphn.com.au or visit our website Quality Improvement in Primary Care.

 

Resources for practices

MBS Online – Upcoming changes to the MBS Chronic Disease Management Framework

MyMedicare Program Guidelines

MyMedicare GP toolkit

Changes to chronic disease management MBS items begin 1 July

02 June 2025

The Department of Health, Disability and Ageing’s changes to the Medicare Benefits Schedule (MBS) framework for chronic disease management in primary care will come into effect on 1 July.

The new Chronic Condition Management model aims to simplify, streamline and modernise chronic condition care, improving access and continuity for patients managing long-term conditions. 

These changes primarily affect medical practitioners, however, allied health professionals providing MBS services should be aware of the changes to plan and referral requirements.

CDM Plus will present two free webinars on the changes. Details below

 

At a glance

The changes will:

  • Replace the current GP Management Plan (GPMP) and Team Care Arrangements (TCA) with a single GP Chronic Condition Management Plan (GPCCMP)
  • Support continuity of care by requiring patients registered for MyMedicare to access management plans and reviews through the practice where they are registered. Patients who aren’t registered will be able to access management plans through their usual GP
  • Encourage management plan reviews by:
  • Equalising the fees for developing and reviewing plans (see new MBS item numbers below)
  • Requiring patients to have their plan established or reviewed in the previous 18 months to continue to access allied health services
  • Formalise referral processes for allied health services so they are more consistent with other referral arrangements
  • Ensure patients do not lose access to their current services through transition arrangements for existing patients with GPMPs and TCAs
  • Practice nurses, Aboriginal and Torres Strait Islander health practitioners, and Aboriginal health workers can assist in preparing or reviewing plans

 

Other key points for GPs:

  • There will be a transition period of two years to enable people currently on GPMP’s to be transferred to GPCCMPs. Any new plan or review completed after 1 July needs to be a GPCCMP and meet the appropriate referral requirements
  • Patients who had a GPMP or TCA in place prior to 1 July 2025 will be able to continue to access services consistent with those plans for two years. From 1 July 2027, a GPCCMP will be required for ongoing access to allied health services
  • Consistent with current arrangements, unless exceptional circumstances apply, a GPCCMP can be prepared once every 12 months (if necessary) and reviews conducted once every three months. New plans do not need to be prepared each year, existing plans can continue to be reviewed
  • There will be no change to eligibility criteria, ie a condition present or likely to be present for more than six months. There is no specific list of eligible conditions. It is up to GP discretion to determine if someone would benefit from GPCCMP
  • A patient may still be on a GPCCMP even if no multi-disciplinary care is required
  • Where multidisciplinary care is required, patients will be able to access the same range of services currently available through GPMP and TCAs

 

Other key points for allied health providers:

  • Current Enhanced Primary Care (EPC) plans will remain valid until plans are complete. Patients will then need to transition to the new referral pathway. Any new allied health referrals after 1 July need to be completed using the new referral pathway
  • GPs and prescribed medical practitioners will refer patients with a GPCCMP to allied health services directly. The previous EPC referral form will no longer be needed
  • The requirement to consult with at least two collaborating providers, as described under the current TCA, will be removed
  • There is no longer a need to have confirmed acceptance from the allied health provider, however the provider still needs to meet their reporting requirements
  • Referrals are valid for 18 months unless otherwise specified by the referring GP
  • The number of allied health visits remain at a maximum of five per year
  • Referrals can be signed and transmitted electronically. There are minimum requirements which must be included in the referral letter

 

MBS items

From 1 July 2025:

  • Items for GPMPs (229, 721, 92024, 92055), TCAs (230, 723, 92025, 92056) and reviews (233, 732, 92028, 92059) will cease and be replaced with a new streamlined GPCCMP (see table below for item numbers)
  • To encourage reviews and ongoing care, the MBS fees for planning and review items will be equalised. The fee for the preparation or review of a plan will be $156.55 for GPs and $125.30 for prescribed medical practitioners
  • These changes do not affect multidisciplinary care plan items (231, 232, 729, 731, 92026, 92027, 92057, 92058)

Table 1: Chronic Condition Management Items commencing 1 July 2025*  

Name of item 

GP item number 

Prescribed medical practitioner item number 

Prepare a GP chronic condition management plan – face to face 

965 

392 

Prepare a GP chronic condition management plan – video 

92029 

92060 

Review a GP chronic condition management plan – face to face 

967 

393 

Review a GP chronic condition management plan – video 

92030 

92061 

 

Factsheets on upcoming changes to Chronic Disease Management Framework

For more information, the following factsheets are available from MBS Online:

Allied Health Providers (updated: 6 June 2025)

Practice Nurse, Aboriginal Health Workers and Aboriginal and Torres Strait Islander Health Practitioners (updated: 6 June 2025)

Transition Arrangements for Existing Patients (updated: 22 May 2025)

Referral Arrangements for Allied Health Services (updated: 22 May 2025)

MBS Items for GP Chronic Condition Management Plans (updated: 22 May 2025)

 

Support is available

For support on MyMedicare and upcoming GPCCMP changes, please contact your Practice Advancement/Practice Support Officer.

12 March 2025

Lung cancer and its prevalence in Australia

According to the Australian Institute of Health and Welfare (AIHW), lung cancer is one of the top five most commonly diagnosed cancers in Australia. In 2022 lung cancer was the most common cause of cancer death in Australia. Due to the low survival rate of lung cancer and the increase in incidence rates, the AIHW estimates that in 2024 lung cancer will again be the most common cause of cancer death in Australia.

There was an estimated 8.918 deaths from lung cancer in 2024

(Cancer Australia)

 

National Lung Cancer Screening Program (NLCSP)

To address the high mortality rates associated with lung cancer, the Australian Government in partnership with Cancer Australia and the National Aboriginal Community Controlled Health Organisation (NACCHO) has developed the National Lung Cancer Screening Program (NLCSP).

The NLCSP which is due to rollout in July 2025, has been designed to increase early detection of lung cancer and therefore optimising effective treatment options. The program offers eligible patients who are deemed at high risk of developing lung cancer, the option of undergoing a low dose computed tomography (LDCT) scan to increase the possibility of detecting any abnormalities or early-stage cancer.

Eligibility

People will be eligible to participate in the program if they:

  • are aged 50-70, and
  • show no signs or symptoms suggestive of lung cancer (for example persistent cough, coughing up blood, shortness of breath), and
  • have a history of at least 30 pack-years of cigarette smoking and are still smoking, or
  • have a history of at least 30 pack-years of cigarette smoking and quit in the past 10 years.

 

MBS items

The NLCSP will have two new Medicare Benefits Schedule (MBS) item numbers associated with the LDCT scans for eligible patients. More Information on these item numbers will be available on the MBS website from July 2025.

 

How the screening plan will be implemented

The Australian Government Department of Health and Aged Care has outlined four main steps involved in the NLCSP:

  1. Healthcare provider checks eligibility and asks patient age and smoking status.
  2. If patient consents to participate in the program, the healthcare provider refers the patient for an LDCT scan.
  3. Patient has LDCT scan completed by radiology provider.
  4. Patient and healthcare provider receive scan results to discuss and arrange any follow-up tests (if required). If LDCT scan has nil abnormalities the National Cancer Screening Register (NCSR) will notify patient of results and send reminder for repeat screening in two years.

 

Flowchart showing how patients will start by seeing their GP, then agree to participate in the NLCSP and get a referral scan, then get the scan, then get their results. Depending on the results the patient will either see their GP for next steps or screen again in two year's time.
(Australian Government Department of Health and Aged Care)

 

General practice role in cancer screening

Primary care practices play a pivotal role in the promotion and implementation of cancer screening programs as they are usually a person’s first point of contact. According to the Cancer Institute NSW, participation in cancer screening programs reduces cancer related illness and mortality. General practice’s involvement is crucial in ensuring patients are guided through appropriate screening pathways, receive timely follow-ups, and access to early interventions.

Healthcare providers in general practice will assist in determining patient eligibility and working with radiology providers to refer eligible patients for LDCT scanning. Sometimes screening may require further investigation and follow-up testing, in these cases the patient would return to their healthcare provider to discuss these options following relevant clinical guidelines.

 

How your practice can prepare for the NLCSP

It is important to ensure primary care practices are ready to promote the program with eligible participants and be ready to make referrals. Whilst the program is not released yet, there are a few things your practice can do to ensure that your practice is ready:

  • Review information about the program on the Department of Health and Aged Care’s website Department of Health and Aged Care | National Lung Cancer Screening Program.
  • Register and integrate with the National Cancer Screening Register (NCSR). More information can be found on the NCSR website National Cancer Screening Register | Accessing the NCSR, including links to user guides and walkthrough video guides.
  • Identify patients who could be eligible from July 2025. This includes reviewing and updating smoking history in clinical patient records.
  • Ensure patients’ smoking status is routinely asked and accurately recorded in the clinical software. This can be achieved by incorporating smoking history questions into your practices standard consultation process and maintaining consistent and correct documentation.

SWSPHN has some useful resources for documenting in the correct location within a patient record, and how to perform a POLAR search to assist your practice in measuring the smoking status recording rate.

Clinical Guide for Best Practice Software | How and where to document – Data Cleansing

Clinical Guide for MedicalDirector Software | How and where to document – Data Cleansing

POLAR Walkthrough – Data Quality

 

Helpful tips for GPs, managers and nurses

Private bookmark

The Private Bookmark Function in POLAR allows the user to save searches of specific patient cohorts by creating a bookmark. The user can create these bookmarks by clicking the tab at the top right-hand corner of the page.

Note: Private bookmarks saved in the Clinic Summary Legacy report will not be transferred to the new Clinic Summary Beta report when the Legacy report is decommissioned.

POLAR QIPC Report - cancer screening. Location of Bookmarks link.

Download Private Bookmark Walkthrough

 

Correct documentation

For POLAR to obtain precise and reliable data, it is crucial to ensure every item is accurately documented in the patient’s file. To assist clinicians and practice staff in documenting care items in the appropriate location in their clinic’s medical software, data mapping of each tab is accessible in the Help menu.

POLAR QIPC Report location of Help menu.

If you wish to find out more about cancer screening in POLAR or SWSPHN’s QIPC program, please email cqisupport@swsphn.com.au or visit our website Quality Improvement in Primary Care.

 

02 December 2024

Quality improvement (QI) activities improve clinical care and patient outcomes in general practice. The RACGP defines continuous quality improvement as an ongoing activity undertaken within a general practice with the primary purpose of monitoring, evaluating or improving the quality of healthcare delivered to practice patients.

 

What are QI toolkits?

Due to the complexity and time constraints in primary healthcare settings, completing QI activities can be a daunting task for healthcare providers. QI toolkits are structured sets of tools, methods and resources designed to help organisations in improving health outcomes, such as increasing the rates of early diagnosis or optimising treatment pathways.

South Western Sydney PHN (SWSPHN) has created a range of QI toolkits tailored to assist your practice in identifying and planning data-driven QI activities, on selected clinical topics. The toolkits are designed to make implementing measurable and sustainable improvements easier and will help your practice complete QI activities using the Model for Improvement (MFI).

 

Who can use the toolkits? How do they benefit your practice?

Practices participating in the Quality Improvement in Primary Care program (QIPC) or anyone interested in knowing more about QI in the general practice setting can utilise the QI toolkits. The activities in the toolkits can assist in maintaining continuing professional development (CPD) requirements, and help your practice meet the requirements for the Practice Incentive Program Quality Improvement (PIP QI).

 

How to use the toolkits?

The QI toolkits provide guidance with various QI ideas, walkthroughs and resources to assist your continuous QI activities on different topics e.g. heart health and hepatitis C. Each QI toolkit is presented in a similar format for easy navigation, including:

  1. Foundation of Quality Improvement
  2. Quality Improvement Activities
  3. Tips and Tricks
  4. Helpful Resources

Practices can use any resources from the above sections of the QI toolkits which best meet your needs and adapt them for your purposes.

Screen grab showing the bookmark links found in each toolkit providing a consist structure of Foundations of QI, Quality Improvement Activities, Tips and Tricks, and Helpful resources
Each toolkit offers a similar format and is bookmarked for quick navigation.

 

 

  1. Foundation of Quality Improvement

This section is the same for all the QI toolkits and can be accessed to find out more information on the foundations of QI. It has an easy-to-follow walkthrough on how to complete the MFI to keep track of your QI activities progress, and also an MFI template to utilise for your selected focus areas.

Screen grab showing where to find links to Foundation of Quality Improvement documents in each toolkit.
Find links to Foundation of Quality Improvement documents in each QI toolkit.

 

  1. Quality Improvement Activities

In the QI activities section of each toolkit, you will find categories such as:

  • Data Cleansing – Update and improve your patient’s medical records.
  • MBS – Increase revenue for your practice by billing the associated item numbers.
  • Pathology – Maintain patient pathology records.
  • Screening – Identify patients who may benefit from certain types of screening.
  • Management – Treatment options and management of certain health conditions.

This area of the QI toolkits may differ depending upon the toolkit topic, however, under each of these categories you will find suggested focus areas for improvement. Every suggested focus area will have tools to enable your practice to achieve improvement in this area. These tools include:

      • Sample MFI – An example of how to record the progress of your selected focus area.
      • POLAR Walkthrough – This is a guide to assist you in extracting lists of patient cohorts for the selected focus area.
      • Clinical Software Guides (Best Practice and Medical Director ONLY) – These are step-by-step guides to show you how and where to document to ensure patient records for your practice are maintained.

 

  1. Tips and Tricks

This area of the toolkit contains helpful hints such as:

  • Private bookmark – How to create a private bookmark in POLAR to save a search for a selected patient cohort.
  • Data mapping – This shows where and how POLAR picks up the data from within your clinical software and enables you to ensure you are documenting in the correct location, therefore no important data is missed.

 

  1. Helpful Resources

Each toolkit has a selection of helpful resources for the selected toolkit topic. These resources have different headings for ease of use, some of the headings include:

  • Clinical resources – These are resources which provide information for clinicians.
  • Patient resources – These are resources directed at patients.
  • CPD/Webinar – These resources can contribute to your CPD requirements and are specific to the toolkit topics.

 

Assistance and resources

We are continuing to develop new QI toolkit topics, and you can see our latest additions here on the Quality Improvement Toolkits page on the SWSPHN website.

For any enquiries or further information on the QI toolkits please email CQIsupport@swsphn.com.au 

12 June 2024

Hepatitis C (HCV) is a preventable disease due to the high effectiveness of modern treatments and the potential for early detection and intervention. NSW Health is committed to eliminating hepatitis C as a public health concern by 2028, aligning with the World Health Organisation’s (WHO) goal. Central to this effort is the NSW Hepatitis C Strategy 2022-2025, which outlines the comprehensive approach needed to achieve this significant public health objective.

Bar chart showing hepatitis C cases confirmed, treated and cured for the years 2019, 2020, 2021 and 2022. The chart clearly illustrates the number of confirmed cases is much higher than cases being treated. Of treated cases 93-94% are cured. The numbers off all are decreasing slightly each year.

More than 300 Australians die annually from hepatitis C-related causes. As shown in Figure 1, there has been a 93-to-94 per cent cure rate between 2019 and 2022 from the time an individual received treatment. The high cure rates demonstrate the efficacy of hepatitis C Direct Acting Antivirals (DAAs) treatments. By addressing the gap between ribonucleic acid (RNA) confirmation HCV with DAA treatment uptake, Australia can significantly reduce the burden of hepatitis C moving closer to the 50 per cent elimination goal set by WHO.

 

Screening and diagnosis of hepatitis C

Screening is essential for early detection and treatment effectiveness. Priority populations include:

  • individuals with a history of injecting drugs
  • people in custodial settings or with a history of incarceration
  • those living with individuals who have hepatitis C
  • people with human immunodeficiency virus (HIV) or hepatitis B
  • people from culturally and linguistically diverse backgrounds
  • patients with abnormal liver function tests, acute hepatitis, chronic liver disease or liver cirrhosis
  • those who have had cosmetic surgery or dental treatments overseas

Resources for screening and diagnosis

Decision Making in Hepatitis C Tool
Guides healthcare professionals on diagnosis, treatment and follow-up

Webinar for GPs
Enhances GP understanding of hepatitis C testing and treatment

Project ECHO
Supports GPs in screening, managing, and treating hepatitis C and liver diseases.

Useful Training
Collection of resources categorised by disease area or profession in ASHIM learning hub

 

Hepatitis C treatment

Hepatitis C DAAs allow GPs to prescribe effective treatment with a success rate of approximately 95 per cent. DAAs are included in the Pharmaceutical Benefits Scheme (PBS) and are better tolerated by patients. Treatment is between eight to 12 weeks with one tablet a day with minimal side effects.

Resources for treatment

REACH-C Form
Online tool for GPs for timely specialist approval within 24 hours

PBS Information
Details on hepatitis C medication coverage under PBS

Decision-making Tool for Children
Assists clinicians in managing hepatitis C in children

 

Reducing stigma and discrimination around hepatitis C

Stigma and discrimination significantly hinder treatment access for more than 70 per cent of Australians affected by hepatitis C. These negative attitudes often arise from misconceptions about how the virus is contracted.

To combat this, it is crucial to promote open discussions about liver health and normalise the conversation around hepatitis C. Using inclusive and non-judgmental language fosters a supportive environment, empowering individuals to seek the care they need.

Resources for reducing stigma

The Power of Words: Anti-stigma Guide
Encourages the use of welcoming terms to reduce stigma

 

Effective prevention strategies for hepatitis C

Prevention efforts in primary healthcare settings include:

  • promoting safe injection practices and proper disposal of needles
  • sourcing harm-reduction services such as needle and syringe programs, substance use counselling and opioid treatment programs
  • educating patients and staff about liver health and hepatitis C

Resources for prevention

NSP Locations and Contact Details
Access local needle and syringe program outlets

The NSW Users and AIDS Association (NUAA)
Supports individuals impacted by drug use criminalisation

Opioid Treatment Program (OTP)
Offers methadone, buprenorphine or suboxone treatment

 

Empowering patients: resources for hepatitis C support

Motivate C – Treatment Incentive
Motivate C is an incentivised project conducted by the University of Sydney for newly diagnosed hepatitis C patients. The program aims to find out if an offer of a cash reward will encourage people with hepatitis C to seek treatment from community treatment providers. Participants self-register for this study and will be connected with a treatment navigator to guide them through all study procedures. For further information on Motivate C project email project@sydney.edu.au

Patient Pathway Guide
Provides information on testing and treating hepatitis C

Hepatitis NSW Hotline
Offers support and education

Multicultural HIV and Hepatitis Service (MHAHS)
Works with diverse communities to reduce the impact of viral hepatitis

 

POLAR walkthroughs  

SWSPHN has developed a set of POLAR walkthroughs to assist healthcare providers in utilising the Hepatitis report and Clinic Summary report. These walkthroughs focus on identifying and managing cohorts associated with hepatitis C.  

By utilising these walkthroughs and reports, practices can better monitor patient populations, streamline diagnosis and optimise treatment pathways for those affected by hepatitis C. 

Helpful walkthroughs: 

Screen capture showing how to find patients using POLAR

 

For more information or support, contact SWSPHN at cqisupport@swsphn.com.au or visit Quality Improvement in Primary Care (QIPC) resources

18 March 2024

Cancer and its prevalence in Australia

In Australia, according to the Australian Institute of Health and Welfare (AIHW), three out of every 10 deaths are caused by cancer, and it is estimated there were 162,163 new cancer cases diagnosed in 2022.

 

The treatment of cancer can become increasingly challenging as the disease progresses and spreads.

In numerous instances, cancer only presents symptoms after it has metastasised.

Therefore, early detection and screening of the asymptomatic population is crucial in preventing the disease’s advancement and achieving successful outcomes.

What is cancer screening?

Cancer screening detects early signs or risk factors for cancer, increasing treatment success and may prevent cancer.

However, further investigation is necessary for confirmation of positive findings.

There are three different approaches to screening:

  • Population-based screening: This involves testing of an entire target population.
  • Targeted risk screening: This involves screening high-risk individuals, such as those with a strong family history of certain types of cancer.
  • Opportunistic screening: This involves screening conducted during a medical check-up, such as tests which may be ordered by a healthcare professional during an appointment for medication review or a yearly immunisation like the flu vaccine.

Three population-based cancer screening programs in Australia are free for eligible people:

  • BreastScreen Australia Program: Women over 40 can have a free mammogram and women aged 50 to 74 are actively invited to screen every two years.
  • National Bowel Cancer Screening Program: The Australian National Bowel Cancer Screening Program (NBCSP) provides population screening for bowel cancer free of charge to eligible people every two years for ages 50 to 74.
  • National Cervical Screening Program: Women and people with a cervix aged 25 to 74 years are invited to have a Cervical Screening Test every five years through their healthcare provider.

Each program aims to detect pre-cancerous abnormalities or early-stage cancers before symptoms occur, maximising the chance of successful treatment.

Primary healthcare and its role in cancer screening

Primary healthcare providers are essential collaborators and drivers in the promotion and implementation of cancer screening programs.

Patient-centred care and participation in cancer screening programs are critical factors in decreasing cancer-related morbidity and mortality.

NSW Primary Health Framework
 

Studies from Cancer Institute NSW suggest the recommendation or endorsement of cancer screening programs by a primary healthcare provider elevates the participation rate in cervical, breast and bowel screening programs.

Furthermore, healthcare providers play a pivotal role in encouraging individuals to seek and engage in cancer screening programs by providing educational resources and accessible tools.

How can QIPC cancer screening module in POLAR be useful?

Outcome Health and SWSPHN have collaborated to develop a cancer screening module.

This module can be accessed through the POLAR QIPC report and is located under the “Clinical” tab.

Its purpose is to help general practices identify high-risk patients who are due for screening, in order to improve their management and health outcomes.

 

The module has five tabs covering information and trends, cervical screening, breast screening, bowel cancer screening and skin cancer screening.

 

SWSPHN has created a set of POLAR Walkthroughs to assist in utilising the Cancer Screening Module effectively: 

Helpful tips for GPs, managers and nurses

  • Private bookmark: The Private Bookmark function in POLAR allows the user to save searches of specific patient cohorts by creating a bookmark. The user can create these bookmarks at the top right-hand corner of the page. This enables the user to recall specific patient cohorts without having to re-apply filters. This can be a very effective function as it only requires the user to open the bookmarks tab and select their desired saved search.
 
  • Correct documentation: In order for POLAR to obtain precise and reliable data, it is crucial to ensure every item is accurately documented in the patient’s file. To assist clinicians and practice staff in documenting care items in the appropriate location in their clinic’s medical software, data mapping of each tab is accessible in the Help menu.
 
  • Utilising the National Cancer Screening Register: The National Cancer Screening Register (NCSR) gives healthcare providers secure access to patient bowel and cervical screening results and histories. Providers can also submit forms and reports electronically, update patient participation details and view program-related correspondence.
  • Stay current: Several resources and education opportunities are free to keep updated on the latest guidelines and information. An education space eviQ on the NSW Government site has free, evidence-based eLearning resources for health professionals.
  • Providing patient education and resources: Downloadable resources for patients are available from the Cancer Council site.
  • FREE cancer screening educational flipcharts: You can order free cancer screening educational flipcharts in different languages for your organisation. Click here to find more information.
  • Utilising Primary Care Cancer Control Quality Improvement Toolkit: This toolkit aims to assist in incorporating cancer screening and prevention activities into your practice or health service.