This is a More Involved QI – includes free access to Medicoach
Early intervention is critical in chronic condition management because it can significantly improve patient outcomes by enabling earlier detection, more effective treatment, reducing disease progression and complications, and ultimately supporting a longer and better quality of life. Proactive approaches ensure patients receive care when it has the most impact, lowering the risk of preventable hospitalisations and reducing long-term damage. This not only benefits patients but also leads to substantial cost savings for individuals and the wider healthcare system.
Proactive management of chronic conditions also reduces long-term harm and costs—both out-of-pocket for patients and system-wide—by reducing or avoiding downstream care. This QI activity brings “earlier and better” into everyday practice through systematic identification, patient-centred care planning, and health coaching that strengthens self-management.
There are several existing resources you can review to get you started in this QI activity.
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Other improvement ideas
The Healthy North Coast Health Literacy Team are available to help with health literacy training or improvement projects. Contact the HNC Health Literacy Officer for support or free training at your practice or online, at a time that suits you.
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.
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.
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.
Highly regarded by a range of professional supporting those on or starting the dementia journey, the booklet includes commonly asked questions for people to ask their GP and/or specialist.
“It’s a fantastic resource and I give it to everyone on their first diagnosis. Its easy to read, so well planned and thought through and has lots of really useful information, tailored to the region.
I also find it very helpful when educating clinical staff.”
−Geropsychiatric Nurse Practitioner, Mid North Coast.
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.
Strategic Priority Area: One team
Empowering aged care teams to deliver safer, more consistent care.
The Deteriorating Resident Triage Tool (DRRT) supports aged care staff to confidently recognise and respond to signs of resident deterioration. It enables timely, evidence-based decisions, strengthens communication with health services, and promotes early intervention and effective care planning, helping residents receive the right care, at the right time, in the right place. By doing so, it reduces unnecessary Emergency Department presentations and improves resident outcomes.
Developed in collaboration with a specialist geriatrician and informed by input from Residential Aged Care Managers, NSW Ambulance, GPs, and clinical experts across the Mid and North Coast Local Health Districts, the DRRT is practical, relevant, and aligned with contemporary best practice.
Aligned with the Strengthened Quality Standards:
Strategic Priority Area: No one is left behind
Care finders is a free service to assist older adults connect to aged care services and supports. Care finders support older people who experience significant barriers to accessing services, and walk alongside their clients at their own pace, to understand their individual situation and support them to work through the steps to address their needs. Care finders assist people with access to other supports in the community. They can provide connections both with accessing services for the first time, and with changing or finding new services and supports if their needs change.
Care finders can:
The care finder program has been extended to June 2029 and is provided by the following organisations. Each (Lismore, Coffs Harbour, Clarence Valley, Richmond Valley, Port Macquarie-Hastings, Kempsey, Nambucca and Bellingen) and Footprints (Kyogle, Tweed, Byron and Ballina).
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.
Strategic Priority Area: Securing a Healthier Future
Connection and a sense of belonging are protective factors for both individual and community health and wellbeing. Evidence highlights that the social determinants of health play a critical role in addressing many of our regions health challenges.
That’s why Healthy North Coast has long been committed to supporting communities to strengthen and to build social health. Our initiatives, including contemporary ‘Social Prescribing’, help people to connect to activities, supports and each other, and assist communities to integrate services and bridge gaps.
Strategic Priority Area: Improving Lives Now
The Royal Commission into Aged Care Quality and Safety identified several critical areas affecting aged care residents and our health system. Key challenges include:
Telehealth offers valuable opportunities to enhance support for residents living in aged care homes. Funded by the Commonwealth Department of Health and Aged Care, this initiative provides telehealth equipment and staff training as part of the response to the Royal Commission’s findings.
By improving access to primary care clinicians, specialist services, and other service providers through telehealth, we can significantly enhance health outcomes for residents, reducing unnecessary hospital transfers and emergency department visits.
The selection of telehealth equipment was guided by our Healthy Ageing Strategy (HAS), a comprehensive digital discovery questionnaire, and consultation workshops with various stakeholders. These efforts included interviews with residents to understand their attitudes toward telehealth, ensuring the initiative meets their needs and preferences.
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:
These objectives will contribute to achieving the following intended overarching outcomes of:
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
Wellbeing Flexible Funding Criteria & Eligibility
| *Team Size (Total staff and contractors) | Funding Available |
| Small (1-5) | $500-$1500 |
| Medium (6-20) | $1500-$4000 |
| Large (>20) | $4000-$5000 |
