Chronic disease care planning via telehealth workflow

Review workflow, example PDSA and video introduction

Before commencing:

  • Scan the workflow from top to bottom to see what resources are available to you.
  • Read this example activity sheet and PDSA.
  • View this introduction to the workflow video (7:06 mins)  from Medicoach discussing bringing the team together and selecting patients.
  • View Co-designing Team Based Care with Dr Tony Lembke (12:33 min) (scroll to down when you reach the page).
Team meeting: example agenda
  • Advantages of video conferencing (see ideas in workflow below) 
  • Video conference platform options (see healthdirect option in workflow below).
  • Patient selection  (see workflow below for Pen CAT resources)
  •  Improvement idea, goal and measure.
Consider the advantages of video consultation over phone consultation

Video conferences mean:

  • Multiple parties can more easily attend the consultation – for example, family members, carers, support workers or allied health.
  • The person receives additional reassurance and engagement through greater visual contact with you than the phone offers.


Select and install a video conferencing platform
Patient selection

Which patient cohort most needs the care most right now?

See PenCS CAT recipes for groups at risk in COVID-19:

Or ask each doctor for 10 patients with chronic conditions for more than six months.

Determine current CDM status
  • Does the person need a GPMP? If they have a GPMP or TCA, is it for annual review or every two years? Is it due for review?
  • Do a PRODA check to see the person has available MBS numbers.
  • Explain clearly why you are reaching out. Use a strengths-based approach to emphasise heightened care rather than worsening health.
  • Phone, SMS, email/letter invitation (use templates) explaining anything they need to do or bring – for example, family or carer, interpreter, BSL booklet, device, BP readings, step count, SATs.
Book appointments
  • Download flowchart for summary .
  • Confirm whether the consultation is to be via video or phone.
  • Explain in detail what the patient is to expect and anything they need to do at the time of their appointment.

EXAMPLE: In healthdirect Video Call, the patient will click on a link to test their audio and camera, enter their name and telephone number and enter the clinics virtual waiting room. They will hear music while waiting for the clinician.

  • Flag patient appointment in clinical software as video or phone.
  • For video, SMS or email instructions to the patient on how to join the video call.

EXAMPLE: With healthdirect Video Call, you will provide the patient with a URL and an instruction resource is available for you to send to patients.

Send SMS or email appointment reminders
  • Include the URL link to the video call and resend the instructions.
Move clinician seamlessly into a video consultation
  • Check appointment list for the day. If there are video appointments, have a process for checking to see if the patient has joined and have a process in place for notifying clinicians the patient has ‘arrived’.
  • Check equipment at the start of the day for upcoming video consultations. Test both audio and video.

EXAMPLE: When you login to healthdirect Video Call, it has the option to complete a ‘test call’.

  • Ask clinicians to keep their video consultation platform open during the day so it is easy to join the consultation at the time of the appointment.
  • Reception notifies clinician that the patient has ‘arrived’.

EXAMPLE: In healthdirect Video Call, reception staff have access to the ‘waiting room’ and can see when your patients have arrived. They can then notify the clinician in the usual way.

  • When clinician is ready for their next patient, if using healthdirect Video Call, the clinician opens the virtual waiting room, finds the patient and clicks on ‘join the call’.
  • Ensure clinicians have ready access to an alternative phone number for the patient in case there are any issues with the video connection. Clinicians need to confirm the best number to reach the patient on when they first join the video call.
Review chronic disease management guidelines and sick day action plans in Healthpathways

Links to these resources in HealthPathways are summarised for you here:

Create care plan

Obtain an access code from your Primary Health Coordinator or Aboriginal Health Coordinator (see contact details below) for free access to Medicoach learning module: Engaging, Planning and Coaching with your Patients via Telehealth (67:57mins).

The full module contains the following sections:

    • Discuss impacts and considerations for care planning via telehealth (8:22min)
    • Understand how to create engagement and communicate effectively in a virtual format (11:49min)
    • Framing the Consultation (8:33min)
      • Setting the consultation agenda
      • Implementing COVID considerations around prevention and screening activities
      • Coaching your clients through SNAP discussions
      • Disease prevention and screening questions
    • Create self-management agreed goals the SMART way (7:04min)
    • Sick day action planning (3:51min)
    • Telecoaching demonstration (17:53min)
    • Telehealth workflow (2:50min)
    • Reviewing a care plan via telehealth (4:19min)
    • Chronic disease nurse consultations (1:54min)
    • Completing the care (1:22min)

The module also contains the following downloadable resources:

    • Funding opportunities for business continuity
    • Powerful inquires plus SMART goals

Alternatively, review your current care planning discussions to include:

  • RACGP disease-specific questions framed from a coaching perspective
  • Mental health check in
  • Self management goals in a SMART format
  • SNAP
  • Health promotion

Care plan discussions can also include COVID-19 precautions:

  • Flu vaccination
  • Access to script re-fills
  • Coping with self-isolation
  • Avoiding unnecessary excursions – home visiting and home deliveries
  • Scheduled care interventions
  • Personal safety
  • Employment
  • Housing security
Review care plan

Use coaching skills to create engagement:

  • Mental health check in
  • Self management goals
  • SNAP
  • Health promotion


Create a TCA
  • Send referral fax as required. Two practitioners in addition to GP and nurse are needed for a TCA.
Review a TCA
  • Check in to see what support is required.
Follow up PN phone call
  • Discuss COVID-19 precautions
  • Health promotion
  • Review sick day action plans
  • Self management check-in
  • Device use
  • Medication review-scripts due
Billing summary

We'd love to hear from you

Aged Care Disaster Management Planning

Strategic Priority Area: One team

North Coast is identified as the region most likely to be impacted by climate change in Australia and also forecasted greatest growth in those 65+.

Healthy North Coast takes a lead role in ensuring the older population and the sector that supports them are prepared for, can respond to and recover from disasters and other emergencies.

We have led eight regional disaster management capacity building workshops, bringing together SES, community organisations and the aged care sector.

We have also developed disaster preparedness tip sheets for both residential and community aged care providers.

Voluntary Assisted Dying

Strategic Priority Area: One team

In May 2022, the NSW Parliament passed the Voluntary Assisted Dying Act 2022. Effective from Tuesday, 28 November 2023, eligible people have the choice to access voluntary assisted dying. 

Healthy North Coast has developed a webpage for both health professionals and consumers, with links to available information and resources.

Living with Dementia resources

Strategic Priority Area: No one is left behind

Healthy North Coast has worked with people living with dementia, their families and local service providers to develop an information booklet that will help them connect with local and national supports along their journey.

The booklet includes commonly asked questions for people to ask their GP and/or specialist.

The resource is available in digital and printed copies, with more than 5,000 distributed across the region. An e-version is available to clinicians via the Dementia and Cognitive Impairment HealthPathway.

Deteriorating Resident Triage Tool Pilot

Strategic Priority Area: One team

The Deteriorating Resident Response Tool (DRRT) has been developed to guide RN’s in Residential Aged Care homes (RACHs) to better understand, anticipate and make clinical decisions responding to the deteriorating health of residents.

The objective of the DRRT is to give RACH staff clear information to triage and provide appropriate care for a range of residents’ health conditions, and, in turn, prevent unnecessary presentations to ED.

The tool has been designed together with a specialist geriatrician, consulting with stakeholders such as Residential Aged Care Managers, NSW Ambulance, GPs, and experts from Mid and North Coast LHDs.

The pilot commences in March with four participating RACHs. Evaluation measures will include effectiveness in building RN confidence and reported reduction in unnecessary hospitalisations. Findings will inform a future planned, region-wide implementation.

North Coast Care Finders Program

Strategic Priority Area: No one is left behind

The Care Finders program is a free region-wide service to support vulnerable older people who have no-one else to help them, to learn about, apply for and set up support services.

Care finders can help people understand what aged care services are available, set up an assessment, and find and choose services. They also help people with access to other supports in the community, both accessing services for the first time and changing or finding new services and supports.

On the North Coast, Healthy North Coast has commissioned four organisations to provide this important service: EACH, Carexcell, Lifetime Connect and Footprints.

icon with person and hands

Psychological services in residential aged care homes

Strategic Priority Area: Improving Lives Now

Healthy North Coast commissions two service providers to deliver psychological therapies and supports for older people with, or at risk of developing, a mental illness and who are living in residential aged care homes (RACHs).

The aim of the program is to both provide direct support to residents and their families and carers, as well as upskill the RACH workforce to respond to the needs of residents presenting with mental health concerns.

Social prescribing (Healthy Me Healthy Community)

Strategic Priority Area: Securing a Healthier Future

Delivered by Feros Care, the Healthy Me, Healthy Community program aims to build individual and community connections to reduce loneliness and improve wellbeing in Port Macquarie.

The program helps people to connect with community, activities, supports and services that address their broader social determinants of health, as an alternative or supplement to a clinical approach.

icon with person and hands

Digital Health in Residential Aged Care

Strategic Priority Area: Improving Lives Now

Timely access to primary health care professionals, whether through face-to-face consultation or telehealth, is recognised as an issue for many Residential Aged Care Homes (RACHs), that in some cases can lead to potentially preventable hospitalisations. RACHs require adequate telehealth facilities to support access to virtual consultations for their residents.

Project goals

  • Assist participating RACHs to have appropriate telehealth facilities and equipment to enable their residents to virtually consult when needed with their primary health care professionals, specialists and other clinicians. 
  • Provide training to participating RACH staff to support them to have the capabilities to assist their residents in accessing virtual consultation services.
  • Encourage increased use of My Health Record by RACHs, to improve the availability and secure transfer of resident’s health care information between RACHs, primary care and acute care settings.
icon with person and hands

Greater Choice at Home Palliative Care Program

Strategic Priority Area: Improving Lives Now

Aims to provide people who have life limiting conditions the opportunity to exercise choice and receive high quality care at home, harnessing improved and better coordinated supports and services that meet their individual needs.

Program objectives:

  • Improve access to palliative care at home and support end-of-life care systems and services (in primary health care and community care)
  • To enable the right care at the right time and in the right place (to reduce unnecessary hospitalisation)
  • Generate and use data to support continuous improvement of services across sectors
  • Use available technologies to support flexible and responsive palliative care at home, including in the after-hours.

These objectives will contribute to achieving the following intended overarching outcomes of:

  • Improved capacity and responsiveness of services to meet local needs and priorities
  • Improved patient access to quality palliative care services in the home
  • Improved coordination of care for patients across health care providers and integration of palliative care services in their region.

Education & training funding elibility

Funding is open to all primary care providers within disaster affected communities across the Healthy North Coast footprint.

Workforce Locum support and R&R funding criteria

  • Available to primary care services in disaster impacted communities within the Healthy North Coast footprint.
  • Available to support short-term workforce coverage, allowing clinicians to rest and recover.
  • Workforce-support funding in total is capped for each site, over a 12-month period:
    • $10k for GPs and/or
    • $5K for nursing and/or
    • $5k administration support and/or
    • $5K allied/pharmacy and other.
  • Funding is not to be used to fill gaps in staffing that have not been able to recruit to and not to replace existing staff.
  • Healthy North Coast will assess requirements and approve available funding directly with the service requesting support.
  • Priority will be given to sites that have immediate, short-term workforce support needs.
  • Requests will be reviewed and supported on a case-by-case basis.
  • Program funding administered via RCTI Agreement (Recipient Created Tax Invoice) to be paid monthly, or on completion of the placement (whichever comes first).
  • Practices will be required to complete a request for payment form monthly, or on completion of the placement (whichever occurs first).

Wellbeing Flexible Funding Criteria & Eligibility

  • Open to all primary care providers within disaster affected communities across the Healthy North Coast footprint.
  • Activity must be purposeful, with the aim of increasing the wellbeing of your team.
  • Requests will be assessed on a case-by-case basis, with funding allocated based on team size.*
  • Following approval by Healthy North Coast, funding will be administered via RCTI Agreement (Recipient Created Tax Invoice) upon providing proof of expenses.
  • Funding cannot be used for the purchase of alcohol, or any other goods or services where the vendor cannot quote their Australian Business Number.
  • Planned activities must occur prior to 30th June 2024.
  • Funding will not be available for retrospective activities.
*Team Size
(Total staff and contractors)
Funding Available
Small (1-5)$500-$1500
Medium (6-20)$1500-$4000
Large (>20)$4000-$5000