Integrated Care


Workstream Goals

An ongoing program is under development with the PHN with Diabetes Integrated Care components across the LHD area:

  • Integrated diabetes clinic including: (i) facility for diabetes teaching among undergraduate students from medicine, nursing and eleven School of Health sciences disciplines, including podiatry and gp/practice nurses; (ii) step down diabetes foot clinic; (iii) primary care annual review facility; and (iv) development of clinical database from patients attending clinic
  • Endocrinologist virtual clinics within general practices
  • Benchmarking and decision support tool for primary care and pipeline development for primary care support and clinical studies
  • Online and face to face primary care health care professional education
  • Joint governance development


The Wollondilly Health Alliance has funded until 30/6/2017 an integrated diabetes programme for the 43,000 people (2000 with diabetes) of the Wollondilly district.  This includes:

  • Primary care support through community diabetes educator and endocrinologist practice virtual clinics and telephone support
  • Patient care closer to home through educator, dietitian, podiatry and videoconferencing endocrinology clinics, along with general practice based case conferencing
  • Patient education
  • Use of Health pathways and risk stratification
  • Creation of a diabetes register including use of the diabetes passport
  • Online education for all health workers
  • Oversight committee
  • Diabetes Peer Support for those with diabetes
  • Prevention
    - Range of media approaches
    - Risk assessment
    - Diabetes Peer Support for those at high risk of diabetes
    - Food supply options/choices
    - Activity venues
    - Feedback approaches

  • Staffing: 1.0 educator, 0.4 dietitian, 0.2 podiatry, 0.2 endocrinologist 0.5 admin
  • Pre-post comparison and process measures

Extension of integrated care across SWS

  • HCP education
  • AusCDEP
  • Case conferencing


The LHD has funded new educator and dietitian in the area.  The PHN would like an integrated approach in the area.


Oran Park

Not worked up.


Interdisciplinary clinic

On Campbelltown campus: step down foot clinic, interdisciplinary diabetes teaching, primary care teaching and assessment service for primary care-planning underway-Charles Sturt University and PHN contributing


Visiting endocrinologist

PHN wish 0.2FTE for each of the 3 services: Macarthur, Liverpool-Fairfield and Bankstown-Lidcombe-to be worked up