Primary Care Transformation

This year, our WentWest Primary Care Transformation and Integration team provided support to 350 general practices in our region. In our annual needs survey, 83% of Practice Managers rated the support received in improving their practice systems as high or very high. Almost half of general practices in our region operate with two to five regular GPs and 37% of GPs operate independently, so our team is constantly adapting the support we provide based on individual practice needs.

Our Quality Improvement program includes team-based approaches, peer review, reflective practice, best practice and data analysis. Our teams collaborate with practices to understand their needs and provide them with the data tools and learning opportunities to improve their capacity and capabilities.

  • 1,577,478 active patients
  • 340 general practices
  • 24 PCMHs
  • 242 pharmacies
  • 64 RACFs

Patient Centred Medical Homes

We have been researching and implementing a Patient Centred Medical Home (PCMH) model of care in 
Western Sydney since 2014 and now have 24 PCMH practices in our region.

Patient Centred Medical Home

2015 brochure cover


2017 brochure cover


2020 brochure cover


2023 brochure cover


What Our PCMH Practices Have Achieved This Year

This past year, our PCMH practices have been hard at work implementing the four foundational building blocks of Bodenheimer’s 10 Building Blocks of High Performing Primary Care. So, what have our PCMH practices been working on?

  • 1.
Engaged Leadership
  • 2.
 Data-Driven Improvement
  • 3.
 Patient Registration
  • 4.
 Team-Based Care
  • Undertook leadership courses
  • Implemented regular team meetings to discuss the external health
 environment and practice priorities
  • Discussed practice priorities daily to align staff towards a common goal
  • Improved Registrar training
  • Improved onboarding processes
  • Undertook whole-team-training on Coding, Data, Topbar and My Health Record
  • Empowered registered nurses to train in chronic disease management
  • Facilitated a staff feedback session and survey
  • Introduced work-from-home flexibility for all team members
  • Improved care systems for GP Pharmacist role
  • Set up team outdoor lunch meetings
  • Improved data systems that track clinical (e.g. cancer screening and diabetes
 management), operational (continuity of care and access) and patient
 experience metrics
  • Appointed a Quality Improvement (QI) champion in the team
  • Engaged in Cardiology in Community program to improve Cardiovascular
 Disease risk data
  • Utilised Lumos reporting for QI
  • Engaged the whole team in data reports to drive joint QI efforts
  • Utilised QI tools, such as PenCAT, TopBar, Cubiko, PROMIS 29, Post-COVID
 and mental health questionnaires
  • Improved the proportion of active diabetic patients with an HbA1c test
 recorded on file by 20%
  • Used the Model for Improvement to identify abnormal variations in data and
 trigger active participation in Diabetes management and Renal disease
  • Recalled patients over 70 years who had not had a Bone Mineral Density test
  • Used COPD data to increase the number of patients who received an influenza
 vaccination from 55% to 78.6%
  • Registered more patients with Care Monitor for better care planning, patient
 engagement, population management, and patient self-management
  • Utilised Patient Reported Experience Measures
  • Improved process for New Patient Onboarding
  • Utilised disease registries
  • Implemented systems for triage and management of COVID-19 patients
  • Maintained strong connections to patients by doing home visits
  • Set up video conferencing, E-Scripts, E-Pathology, and Secure Messaging
 for patients
  • Employed a dedicated Chronic Disease Management Nurse
  • Worked with a GP Pharmacist
  • Worked with the Western Sydney Diabetes team
  • Collaborated with partners across the Healthcare Neighbourhood
  • Improved team oversight of patient care using Care Monitor
  • Collaborated as a team, including GPs, pharmacists, and nurses, to complete
 care plans, health assessments and home medication review
  • Worked as a team on the pilot Caring for COVID kids in the Community