2025 Annual Report

firsthealth Limited trading as Murrumbidgee Primary Health Network (MPHN) (ABN 15 111 520 168).

Murrumbidgee Primary Health Network gratefully acknowledges the financial and other support from the Department of Health and Aged Care. The Primary Health Networks Program is an Australian Government Initiative.

While the Department of Health and Aged Care has contributed to the funding of this material, the information contained in it does not necessarily reflect the views of the Australian Government and is not advice that is provided, or information that is endorsed by, the Australian Government. The Australian Government is not liable in negligence or otherwise for any injury, loss or damage however arising from the use of or reliance on the information provided in this material.

We acknowledge and pay respects to the traditional owners of the lands on which MPHN operates; the Wiradjuri, Nari Nari, Wemba Wemba, Perepa Perepa, Yorta Yorta, Ngunnawal, Ngarigo, Bangerang and Yitha Yitha Nations. We recognise our communities are made up of many Aboriginal and Torres Strait Islander peoples descended from additional mobs and clans who also call the Murrumbidgee region home.

We pay respect to elders past, present and future and recognise these lands have always been places of traditional healing and medicine, and this plays a role in shaping future health services.

250,744 population

508 communities

126,124km land area

0.1-16.6 persons/km2 population

15,437

54,843 over

125,807

124,938

Wagga Wagga Riverina Western Border

Edward River

Murray River Berrigan Federation

Greater Hume Shire Lockhart Wagga Wagga

Snowy Valleys Cootamundra -Gundagai Regional

Hilltops

Junee

Coolamon Temora Bland

Lachlan (part) Carrathool

Hay

Murrumbidgee

Gri th Leeton Narrandera

17,796 Aboriginal and Torres Strait Islander (7.2%)

74.1 years life expectancy

2,480 over 55 years (13.9%)

WIRADJURI

higher prevalence of cardiovascular disease, diabetes, kidney disease and cancer higher prevalence of mental health conditions

*Artistic impression only

NGARIGO

NGUNNAWAL

CHAir report

As I prepare to conclude my term as Board Chair and Director, I find myself reflecting on the remarkable journey of MPHN over the past nine years I’ve been on the firsthealth Board, six of which as Board Chair. It has been an honour and a privilege to serve this organisation and witness its transformation into a strategic, community-centred leader in primary healthcare.

When I joined the Board, the PHN program was still in its infancy. Today, MPHN is a high-performing commissioner, a trusted partner in health system reform, and a strong advocate for rural and regional communities. Our ability to translate national policy into local solutions reflective of our communities’ lived experience and expertise of our healthcare professionals is something I am deeply proud.

Over the years, we’ve strengthened our partnerships, particularly with Murrumbidgee Local Health District (MLHD), through our Collaborative Agreement, joint planning initiatives, and the establishment of a joint Board between both organisations, which is an uncommon and progressive governance approach. Together, we’ve built a one health system mindset prioritising integration, coordination and community voice.

We’ve also led innovation in commissioning, digital health, suicide prevention, and chronic disease care. Programs like Living Well, Your Way, Enhancing Paediatrics in Primary Care, and the Diabetes Regional Education, Access and Management program are examples of what’s possible when we co-design with providers and communities.

Our work in supporting general practice, aged care, allied health and pharmacy has helped build capacity and resilience across the region.

Importantly, MPHN has remained grounded in community. Through initiatives like Conversations and Yarns on the Couch, we’ve listened deeply and responded meaningfully. Our commitment to equity, inclusion and reconciliation has grown stronger each year.

As the health system continues to evolve, PHNs have a vital role to play, not only in implementing reform, but in championing the needs of local communities and healthcare providers. MPHN is well-positioned to continue leading this work with integrity, agility and purpose.

To my fellow Board members, the executive team, and all MPHN staff, thank you. Your passion, professionalism and dedication have made this journey so rewarding. I leave with immense pride in what we’ve achieved and great confidence in what lies ahead.

Dr Jodi Culbert

CeO report

This year marks my first full year as CEO of MPHN...

and it’s been a year of listening, learning and building relationships. I’ve had the privilege of meeting many passionate people across our region, healthcare providers, clinicians, community members and health advocates, all committed to improving health outcomes in the Murrumbidgee.

Together, we’ve delivered almost $30 million in government funding across more than 300 contracts, supporting initiatives aligned with our purpose to create connected, dynamic and equitable healthcare through empowered workforce and communities.

In 2024/25, MPHN demonstrated strong financial stewardship and resilience in a dynamic environment. Prudent budgeting and robust controls enabled delivery of key strategic initiatives while maintaining stability. Revenue reached $45.2 million, a four percent increase, and expenditure was managed at $44.1 million. This supported $6.8 million investment in critical programs and infrastructure. Resources were carefully allocated, driving operational efficiencies and effective cost management.

As we deliver on our commissioning, coordination and capacity building role, we’re proud of this year’s achievements. We opened two Medicare Mental Health Centres in Wagga Wagga and Young, launched the GPbased Urgent Care Service, and introduced initiatives including The Doctor’s Table, Allied Health Forum and the Murrumbidgee First Nations GP Toolkit. We also supported people experiencing homelessness to access coordinated healthcare.

With our Strategic Plan at its midpoint, we reviewed progress and reaffirmed our commitment to innovation, collaboration and equity. We’ve strengthened support for general practice, aged care, allied health and pharmacy. Our team’s work has been recognised nationally, including awards and conference presentations for the communitydesigned Connect, Your Way mental health campaign.

Internally, we’ve focused on enhancing our culture, and improving systems and processes to remove barriers and boost productivity. We’ve also made meaningful progress against our Reconciliation Action Plan.

I extend my sincere thanks to Dr Jodi Culbert for her six years as Board Chair during her nine-year term as a Director. Her visionary leadership and unwavering commitment to balancing the needs of community, clinicians and policy leaves an enduring legacy that will continue to shape MPHN and the Murrumbidgee region.

Looking ahead, MPHN remains committed to sound financial Governance, positioning us for continued growth and sustainable impact. I’m excited to keep working with our communities and partners to build a healthier, more connected system as we move towards our vision of well people, resilient communities across the Murrumbidgee.

Stewart Gordon

Our board

Dr Jodi Culbert (Chair)

Jodi was a physiotherapist before returning to study as a GP In 2011. As well as being a busy clinician in her own General Practice, Dr Culbert is also committed to serving the broader medical and general Wagga Wagga community. She has particular clinical interests in musculoskeletal medicine, mental health and multidisciplinary preventative health.

Dr Jacques Scholtz

Jacques is a GP obstetrician in Cootamundra who’s also interested in family health and a strong voice for palliative care provision. He participates on Murrumbidgee Local Health District and MPHN committees and is the principal/ owner of a large general practice. He stands for equitable healthcare across all segments of society and works towards an integrated primary healthcare model.

Peta Larsen

Peta, an Accredited Practising Dietitian, has held senior health management positions providing leadership to health professionals. With a passion to improve community health and wellbeing, Peta contributes to clinical quality and safety as a member of the LiveBetter Clinical Governance Committee and the LikeMind Wagga consortium.

Paul Gianniotis (Treasurer)

Paul is the director of a livestock equipment company, with a background in project management. Paul is passionate about addressing the challenges faced in delivering effective integrated healthcare to our significant region. He also has broad involvement in the local business and sporting communities.

Christine Howard

Christine is the Director of Charles Sturt University’s Three Rivers Department of Rural Health. With more than 30 years’ experience working in rural health, Christine has diverse executive health management and leadership experience. She is passionate about the Murrumbidgee region and improving rural health outcomes.

Catherine Ryan

As Practice Manager of a rural, solo general practice in the Murrumbidgee, State President of Australian Association of Practice Management, and a Department of Health and Aged Care, Practice Management Advisory Group member, Catherine brings a wealth of knowledge and experience in practice management and preventative health.

Dr Alam Yoosuff

Alam is a rural GP from Finley NSW with particular interests in public health, palliative care and emergency medicine. Alam has been working as the principal GP at Finley Regional Care and GP/ VMO at Finley Hospital since 2008. He is passionate about providing better health outcomes to rural and remote communities in the region.

Rene Pennock

Rene is an experienced health sector consultant, who has worked extensively with allied health, nursing and medical professionals. Formerly the CEO of South Western Sydney Primary Health Network, Rene has qualifications in physiotherapy and gerontology, and is committed to improving the health of the communities he serves.

Sophie Ryan

Sophie is a strong believer in equitable healthcare. Serving as CEO of Sony Foundation, Sophie has worked closely with hospitals, Government and corporates to fund projects which are delivering better health outcomes. She also has a legal background and strong foundations in Governance and strategic thinking.

Our senior leadership team

Stewart Gordon Chief Executive Officer

Appointed as CEO in July 2024, Stewart is committed to working collaboratively with all communities and stakeholders across the Murrumbidgee to improve health outcomes. With a career of more than two decades working in senior executive roles, Stewart has a deep appreciation and understanding of the challenges of living rurally and how this relates to health.

Anita McRae

Senior Manager, Priority Populations

Anita’s mental health career started in support work and community development, before moving into management roles. Anita’s ongoing passion is that everyone deserves access, in every meaning of the word, to the supports required to live a fulfilling and meaningful life.

Kristy Hawkins

Senior Manager, Corporate Services

Kristy is an experienced human resources generalist with 15 years’ experience working in primary healthcare and holds a Bachelor of Business (Human Resource Management/Accounting). She is passionately interested in people and developing a strong workplace culture with a focus on staff wellbeing.

Narelle Mills

Executive Integration and Partnerships

Narelle has almost 30 years’ experience in primary health program development and implementation and holds an Honours Degree in Applied Science, Graduate Certificate in Public Sector Management and a Masters in Business Administration. Her special interests are in health system integration, paediatrics, aged and palliative care, and quality improvement.

Alison Jansen

Senior Manager, Primary Care

Engagement

Ali has dedicated nearly three decades to the primary healthcare sector, bringing a wealth of experience to MPHN since joining in 2015. She is deeply committed to supporting primary care, with a special emphasis on building workforce capacity.

Toni Preuss

Senior Manager,

Integration

Toni has been with MPHN since 2006, bringing her expertise from roles in workforce, commissioning, and integration programs. Toni is passionate about collaborating with healthcare providers to enhance outcomes. Toni holds a Bachelor of Business Studies and a Masters of Business Administration.

Julie

Redway Executive Commissioning and Operations

Julie has a passion for delivering outcomes for health service providers and consumers. Julie holds a Bachelor’s in Medical Science, Masters in Health Service Management and is a graduate of the Australian Institute of Company Directors (AICD).

Janelle Dufty

Senior Manager, Commissioning

Janelle has worked for MPHN for ten years and was appointed Senior Manager Commissioning in March 2022. Interested in how minds work, Janelle completed postgraduate studies in psychology in 2013. Janelle has an affinity for data and how it relates to decision making.

Dr Jason Bennie (PhD) Chief Data Officer

Jason has an extensive background in public health research and expertise in epidemiology, biostatistics, and health promotion. Jason has a PhD in Behavioural Epidemiology and more than 15 years of experience in managing large-scale public health projects from conception to execution to evaluation.

Measuring our impAC t

To mark the half-way point of its Strategic Plan 2023-2027, MPHN developed an Impact Report to demonstrate its progress towards the vision of Well People, Resilient Communities across the Murrumbidgee.

In late 2022 MPHN released its 2023-2027 Strategic Plan and since then the team has been focussed on delivering a range of activities and initiatives to drive progress under the plan’s three focus areas:

INVEST IN COMMUNITIES FOR IMPROVED HEALTH OUTCOMES

SUPPORT PROVIDERS AND ENHANCE COLLABORATION FOR STRONGER PRIMARY HEALTHCARE

LEAD INNOVATION AND INSPIRE FOR POSITIVE IMPACT

Twelve priorities areas are linked to the focus areas and these guide MPHN in its work.

Since work commenced to implement this Strategic Plan, more than $53 million across 320 contracts has delivered:

78,391 mental health occasions of service to 5,000 participants 17,424 occasions of service to First Nations people across a range of programs

8,852 enrollments in Living Well, Your Way pathways

20,077 occasions of allied health service

MPHN CEO Stewart Gordon said while progress was being captured since inception, it was time to conduct a deep dive into the organisation’s progress to understand its impact.

“Halfway through the term of this strategic plan is an opportune time for us to reflect and take stock of our progress and impact against the focus areas and priorities,” Mr Gordon said.

“The impact report is a high-level overview of the activity and impact of the organisation since 1 January 2023 through to 1 March 2025.

“The MPHN team and its partners have achieved much since January 2023 despite an increasingly complex and changing external environment. However, there is much opportunity to leverage as we look to the final two and half years of the current strategic plan.”

“While the list of impact statements is by no means exhaustive, they do provide some detail and representation of the impact of the work MPHN has undertaken over the past two and a half years,” Mr Gordon said.

“It was also important for us to map activities against the three Cs of a PHN’s purpose which are Coordination, Commissioning and Capacity building.

“So, what this means is being able to identify what activities have supported better coordination and integration with local healthcare services in collaboration with providers including Murrumbidgee Local Health District (MLHD) to improve quality of care, people’s experience and efficient use of resources. Second, what we have commissioned in terms of primary care and mental health services to address population health needs and gaps in service delivery and to improve access and equity. And finally, how we have provided capacity-building opportunities and practice support to primary care and mental health providers to support quality care delivery,” he said.

Taking time to review its impact to date has enabled the Board and the organisation to reaffirm its commitment to the focus areas and priorities outlined in the Strategic Plan.

“While the list of impact statements is by no means exhaustive, they do provide some detail and representation of the impact of the work MPHN has undertaken over the past two and a half years.”

STEWART GORDON, MPHN

KEY STRATEGIC PLAN

ACHIEVEMENTS SINCE 2023

FOCUS AREA 1

INVEST IN COMMUNITIES FOR IMPROVED HEALTH OUTCOMES

Murrumbidgee LGBTQIA+ Health Needs Assessment

Murrumbidgee First Nations Toolkit for General Practice

Homelessness health support

Award winning mental health campaign – Connect, Your Way.

Vaccination pop-ups at Foodbanks across the region

FOCUS AREA 2

SUPPORT PROVIDERS AND ENHANCE

COLLABORATION FOR STRONGER PRIMARY HEALTHCARE

Doctors Table events

Supporting local implementation of nation health reforms

Enhancing Paediatrics in Primary Care initiative

Establishing formalised support structures for allied health professionals

Living Well, Your Way initiative

Collaborative Agreement with MLHD

Advocacy for the Murrumbidgee through engagement with elected representatives

FOCUS AREA 3

LEAD INNOVATION AND INSPIRE FOR POSITIVE IMPACT

Rural pharmacy screening for chronic disease

ASPIRE trial – a systems approach to enhancing community-based medication review

Murrumbidgee DREAM team – bringing specialist diabetes care to rural NSW

To read the full Impact Report visit mphn.org.au.

repor t 2023-25

SnApSHOt of 2024-2025

CONTRACTS

$29,439,392 commissioned

318 contracts

MENTAL HEALTH

MEDICARE MENTAL HEALTH CENTRES

10,650 occasions of service

727 participants supported

MYSTEP TO MENTAL WELLBEING

19,432 occasions of service

MURRUMBIDGEE PATHWAYS ALCOHOL AND OTHER DRUGS (AOD) ENHANCEMENT

169 participants supported PSYCHOSOCIAL SUPPORTS

13,546 occasions of service

FIRST NATIONS

PRACTICE VISITS AND TOOLKIT DISTRIBUTION

21 face-to-face practice visits by MPHN

134

Murrumbidgee First Nations Toolkit for General Practice distributed

INTEGRATED TEAM CARE (ITC) PROGRAM SERVICES

15,531 occasions of service

AOD PROGRAMS

PRIMARY HEALTHCARE PROVIDER SUPPORT

1,142 practice support interactions

WORKFORCE PLANNING AND PRIORITISATION

24 stakeholders engaged to develop the training pathways report

56 stakeholders engaged to develop the catchment report

IMMUNISATION SUPPORT

100% of general practices received at least one immunisation support visit

CONTINUING PROFESSIONAL DEVELOPMENT (CPD)

41

CPD events

WORKFORCE

5 University of Wollongong students supported

428 attendees

50

GP registrars trained in the Murrumbidgee

YOUTH MENTAL HEALTH

1,566 young people supported 1,740 episodes of care

2,482 occasions of service IN THE COMMUNITY

Griffith Aboriginal Medical Service 682 participants Work It Out

94 participants

LIVING WELL, YOUR WAY

7,596 total patient encounters across all programs

MPHN attended 25+

community events, including:

• Wagga Wagga Homelessness Expo

• Snowy Valley Community Fun Day

• Henty Machinery Field Days

• Junee International Women’s Day

• Multiple Seniors Week events

14

Conversations on the Couch with approximately 130 attendees

3

Yarns on the Couch with 23 attendees

INVEST IN COMMUNITIES

Launched Wagga Wagga Urgent Care Service

100

GP-based appointments per week

WOMEN, MATERNAL AND CHILD HEALTH

WARATAH FOR KIDS 58 children supported 5

22 clinics delivered

new general practices onboarded PREGNANT WOMEN AND MOTHERS PROGRAM

107 participants supported under revised model of care WAGGA WOMEN’S HEALTH CENTRE

1,857

occasions of service

GIDGET HOUSE WAGGA WAGGA

206 occasions of service

HEALTHPATHWAYS

596

localised Murrumbidgee HealthPathways pages

67 new localised pages

55,671 page views VACCINATIONS

123

COVID-19 or influenza vaccines administered at Foodbank pop-up clinics

190 aged care residents vaccinated across 10 residential aged care homes (RACHs)

14

nurses completed MPHN’s Immunisation Scholarship Program

69 pages updated 365 individual users 7 participating general practices in Wagga Wagga

38

COVID-19 vaccines administered at Henty Machinery Field Days 70%

average COVID-19 vaccination rate across RACHs in the region

$66,000+ in grants distributed to nine practices and pharmacies through the Vulnerable Peoples Vaccination Grants Program

MURRUMBIDGEE SUICIDE PREVENTION AND AFTERCARE

MURRUMBIDGEE AFTER SUICIDE SUPPORT PROGRAM

809

individual support contacts

1,801 participants

57 group sessions THE WAY BACK SUPPORT SERVICE

7,113 occasions of service

HEALTHY AGEING AND PALLIATIVE CARE VITALITY PASSPORT

264 participants 81% reduced or halted frailty 86%

improved or maintained quality of life

4.8/5 satisfaction rating

70% accessed mental health support

104 participants in RACHs

CARE FINDER SERVICES

316 participants supported

2,453 occasions of service

PROMOTING HEALTHY LIVING HOMELESSNESS HEALTH INITIATIVES

41 participants supported WARATAH PROGRAM

942 occasions of service

2,722 participants supported

5,695 occasions of service INTEGRATED CARE COORDINATION (ICC)

2,807 occasions of service HEALTH NAVIGATOR PROGRAM

95 participants supported

79 participants supported ASTHMA AND COPD EDUCATION

280 occasions of service

164

people from

13 regional towns

Invest in for improved health outcomes COmmunitieS

2024/25 KEY ACHIEVEMENTS:

Engaged approximately 130 people across 17 communities through Conversations and Yarns on the Couch, ensuring local voices directly shaped the Health Needs Assessment 2025–2028 ...page 14

Launched the GP-based Urgent Care Service in Wagga Wagga, expanding access to fast, bulk-billed urgent care ...page 29

Delivered vaccines and food relief to vulnerable communities through seven Foodbank pop-up clinics ...page 16

Launched the co-designed First Nations Health Strategy, guiding culturally safe, community-led care across the Murrumbidgee region ...page 22

Helped more older people in the Murrumbidgee region stay healthy, connected, and supported ...page 20

Expanded maternal and child wellbeing programs across 10 towns, supporting 58 children, 107 mothers, and delivering more than 2,000 care contacts ...page 30

Medicare Mental Health Centres opened in Wagga Wagga and Young, providing free, walk-in support ...page 26

Improved healthcare access for people experiencing homelessness through a new coordinated model of care ...page 18

Expanded suicide prevention, aftercare, training, and community support services ...page 24

headspace Wagga Wagga selected as one of 30 national sites to receive the new headspace Plus upgrade ...page 28

LISTENING, LEARNING, LEADING:

How COmmunity vOiCeS shape health planning

Through Conversations on the Couch, Yarns on the Couch, and targeted homelessness co-design, MPHN gathered powerful community insights that directly informed the Health Needs Assessment (HNA) 2025–2028, ensuring local voices are at the heart of regional health planning.

Each year MPHN sets out to better understand the health needs of communities across the Murrumbidgee. This commitment continued through Conversations and Yarns on the Couch events, consultations, co-design opportunities, and community surveys. These activities enriched MPHN’s understanding and directly shaped the Health Needs Assessment (HNA) 2025–2028.

Community feedback along with data collected throughout 2024 directly informed the development of the HNA 2025-2028 in early 2025, which highlighted chronic disease, mental health, youth mortality, and increasing homelessness as key challenges for the Murrumbidgee.

MPHN’s Acting Chief Data Officer, Dr Ryan du Toit (PhD), said a more structured approach to capturing community conversations is helping us gain deeper insights and identify emerging needs.

“People sit with us and talk about their healthcare experiences in their town and community. They tell us what matters to them and why. What they share is detailed and personal, and it gives us insights into health experiences that numbers alone cannot show,” said Dr du Toit.

During Conversations on the Couch, we balance notetaking with staying engaged in the conversation. While the information is often disorganised, it is incredibly valuable. We use these notes to identify key themes and emerging issues.”

MPHN’s Community Engagement Coordinator Tom Parker said the 2025 Conversations on the Couch events used the same approach.

“There’s something powerful about meeting people in their own communities,” Mr Parker said.

“Beyond the conversations, we often are able to connect people with services that they weren’t aware of, and for me that’s another way we are supporting the community –creating awareness for services and support too.”

Recognising the importance of culturally safe engagement, MPHN also conducts Yarns on the Couch.

Held in Wagga Wagga, Hay and Gundagai this year, MPHN’s Aboriginal Health and Wellbeing Manager Maxine Honeysett said the Yarns on the Couch initiative is more than consultation.

“To listen and yarn with community members means we can be part of the support network for First Nations people in the region. It’s about showing up, sitting down, and hearing what really matters. It’s about connection and people feel like they can talk to you about barriers and health needs,” Ms Honeysett said.

This year Conversations and Yarns on the Couch events have engaged with around 130 people across 17 communities.

“What they share is detailed and personal, and it gives us insights into health experiences that numbers alone cannot show.”

DR RYAN DU TOIT (PHD), MPHN

attendees

Common themes included challenges accessing GPs and specialists, transport barriers, mental health service gaps, and the rising cost of care. Participants also emphasised the importance of bulk billing and expressed appreciation for local healthcare workers. Unique to the First Nations community, Yarns uncovered specific concerns around the affordability of National Disability Insurance Scheme (NDIS) assessment and specialist appointments, better hospital follow-up, and the need for culturally safe services, which MPHN is supporting through its recent launch of the First Nations GP Toolkit and broader commissioning priorities.

One emerging theme was the growing impact of homelessness on health outcomes across the Murrumbidgee, and insights from a previous Homelessness HNA and subsequent co-design activities with clinicians, social services, and community groups guided the launch of the Homelessness Health Support Program in 2024.

The co-designed model integrated two initiatives including the Homelessness Health Support Team (HHST), delivered by Marathon Health, and GP-led Multidisciplinary Clinics in Junee, Holbrook, Young, Wagga Wagga and Cootamundra.

MPHN’s Senior Lead Engagement and Design Shane Delves said the initiatives work together to provide outreach, care coordination, and primary care for people sleeping rough, couch surfing, or living in unstable housing.

“The model is designed to meet people where they are physically, emotionally, and socially and by integrating outreach with clinical care, we’re not just treating symptoms, we’re building pathways to long-term health and stability,” Mr Delves said.

In June 2025 MPHN also commenced planning for a Multicultural HNA, which will take place in the second part of 2025. This initiative will explore the unique health challenges faced by multicultural communities across the Murrumbidgee, with a focus on improving equity and access to primary care. The assessment will guide tailored engagement strategies, strengthen relationships with multicultural stakeholders, and inform future activities with existing services and potentially commissioning of culturally appropriate services.

These population-specific initiatives reflect MPHN’s belief that health equity starts with understanding and solutions must be built with, not for, the community.

TOWNS VISITED

CONVERSATIONS ON THE COUCH

Howlong

Corowa

Barham

Hanwood

Hillston

Boorowa

Harden

Cootamundra

Batlow

Tumbarumba

Junee

Wagga Wagga

The Rock Holbrook

YARNS ON THE COUCH

Gundagai Hay Wagga Wagga

Conversations on the Couch in Jindera, May 2025

Taking vACCineS where they’re needed most

MPHN continued to strengthen its commitment to improving immunisation rates across the region by working with communities, local organisations, and health providers. From pop-up clinics in rural towns to targeted aged care outreach, MPHN’s efforts have been both strategic and deeply community-focused.

One of the most impactful initiatives this year was our series of Foodbank pop-up clinics, which combined food relief with access to vital health services. These events were held in Young, West Wyalong, Deniliquin, Hay, Leeton, Tumut, and Wagga Wagga. Across these seven clinics, MPHN administered 90 COVID-19 vaccines and 33 influenza vaccines.

In total, more than 16 tonnes of fresh produce were distributed at these events, supporting hundreds of families with enough food for a week. The August Wagga Wagga pop-up alone provided eight tonnes of food to approximately 800 people in just 90 minutes, highlighting the scale and urgency of the need.

MPHN’s Clinical Programs and Emergency Response Manager Peta Anderson said the pop-ups were reaching vulnerable populations who may otherwise face barriers to healthcare.

“When people are facing tough times, their health often slips down the priority list,” Ms Anderson said.

“Through our partnership with Foodbank, we’re not only providing food relief, we’re creating a safe, welcoming space where people can access vital health support without stigma or added stress.”

90

COVID-19 vaccines and

33 influenza vaccines administered at

7 Foodbank pop-up clinics

The success of these clinics was amplified by MPHN’s presence at other key community events, including the Henty Machinery Field Days, where COVID-19 vaccines were administered, and the Wagga Wagga Homelessness Week Expo, which provided health support to people experiencing housing insecurity. MPHN also attended the Snowy Valley Community Fun Day in Tumut, Junee International Women’s Day, and multiple Seniors Week events in towns like Lockhart, The Rock, Gundagai, and Harden.

“These events provide important opportunities to engage directly with the community,” Ms Anderson said.

“Whether at a machinery field day or a seniors’ gathering, our priority is to understand local needs and deliver practical health support.”

38

COVID-19 vaccines administered at Henty Machinery Field Days

16+ tonnes of fresh produce distributed at Foodbank events

Leeton Foodbank, November 2024

In addition to community outreach, MPHN focused heavily on improving vaccination rates in Residential Aged Care Homes (RACHs). Over the past year, 10 RACHs participated in targeted efforts, resulting in 190 residents being vaccinated by nine GPs and pharmacies. The current average COVID-19 vaccination rate across RACHs in the region sits at approximately 70 percent.

MPHN visited multiple aged care facilities, working closely with staff to establish routines and systems that support regular COVID-19 and influenza vaccinations.

“Boosting immunisation in aged care is an important way we can help support people in our communities to live longer, healthier lives,” Ms Anderson said.

“By building strong relationships with staff and residents, we’re more likely to make these programs sustainable.”

190 aged care residents vaccinated across 10 RACHs 70%

average COVID-19 vaccination rate across RACHs in the region

To further build capacity in the region, MPHN offered a nurse immunisation scholarship program, which saw 14 nurses – a mix of practice and aged care nurses –complete the course. This initiative has helped ensure that more local nurses are qualified to administer vaccines, particularly in rural and remote areas. By investing in our workforce, we are empowering nurses to take on immunisation roles in their communities, which is critical for long-term health outcomes.

14 nurses completed MPHN’s Immunisation Scholarship Program

Another key initiative was the Vulnerable Peoples Vaccination Grants program, which provided financial support to practices and pharmacies to increase COVID-19 vaccine uptake. MPHN distributed more than $66,000 in grants to nine providers to help cover staffing, outreach, and logistics. The program allowed providers to tailor their approach, from running extra clinics to conducting home visits, and helped remove practical barriers to vaccination.

$66,000+

in grants distributed through the Vulnerable Peoples Vaccination Grants Program

9

practices and pharmacies participated in the grants program

25+

community events attended by MPHN, including:

✓ Wagga Wagga Homelessness Expo

✓ Snowy Valley Community Fun Day (Tumut)

✓ Junee International Women’s Day

✓ multiple Seniors Week events

In total, MPHN attended more than 25 community events throughout the year, with staff attending expos, forums, education days, and local celebrations. These events not only facilitated vaccine delivery but also strengthened MPHN’s visibility and trust within the community.

Ms Anderson said MPHN remains committed to innovative, community-led approaches to immunisation.

“We will continue to collaborate with local partners, invest in workforce development, and adapt our strategies to meet the evolving needs of the region,” Ms Anderson said.

“We want every person in the Murrumbidgee to have easy, equitable access to vaccines.”

“We’re creating a safe, welcoming space where people can access vital health support without stigma or added stress.”

PETA ANDERSON, MPHN

COnneC ting communities to better health

MPHN is committed to promoting healthy living and improving access to care across the Murrumbidgee region. This past year, that commitment has been brought to life through new initiatives designed to address complex community needs, particularly for people experiencing, or at risk of, homelessness.

A key driver of this work has been the Homelessness Health Needs Assessment (HNA), undertaken in partnership with Beacon Strategies. Findings highlighted significant barriers faced by people without secure housing in timely access to health services. In response, MPHN secured grant funding to commission two targeted activities: the Homelessness Health Support Team (HHST), delivered by Marathon Health, and the Homelessness GP-Led Multidisciplinary Clinics. Together, these programs form the Homelessness Health Support Model of Care, a coordinated approach to reduce health inequities and improve outcomes for this priority population.

MPHN’s Senior Manager Commissioning Janelle Dufty said health is not just about medical treatment.

“It’s about restoring connection and dignity, and ensuring people can access care when and where they need it most,” Ms Dufty said.

“The homelessness initiatives are a step toward showing what can be achieved working collaboratively to increase access to healthcare for everyone.”

The HHST is central to this model. It includes service navigators, care coordinators, and peer workers who provide outreach in partnership with GPs, police, ambulance, and local support services. The team ensures people sleeping rough, couch surfing, or living in unsafe housing can be connected with primary care, medications,

and follow-up support. Since its launch, the HHST has engaged 41 participants, delivering 942 occasions of service. Early results show the value of this model in building trust and linking people with appropriate services. One standout success involved a man in his 60s facing eviction after 12 months without income or engagement with healthcare. Initially hesitant, he is now receiving GP support, medication assistance, and assessments for daily living needs, alongside housing support. He shared that he now feels able to “move forward” thanks to the team’s compassionate approach.

The introduction of the HHST model of care marks a significant step forward in addressing complex health and social challenges across the Murrumbidgee. By combining outreach, navigation, and GP-led care, MPHN and its partners are creating a more inclusive health system.

“Promoting healthy living means working together to break down barriers,” Ms Dufty said.

HOMELESSNESS HEALTH INITIATIVES

41 participants engaged

942 occasions of service delivered

WARATAH for Kids program being delivered by Marathon Health

“Whether it’s supporting someone to attend their first GP appointment in years, helping a person quit smoking, or building better systems for chronic care, every step contributes to a healthier, stronger Murrumbidgee community.”

VeCare Health Holbrook and Boorowa Street Medical Practice have established GP-led clinics dedicated to people at risk of homelessness. These clinics provide essential services such as wound care, management of chronic conditions, sexual and reproductive health, and support for infections. The clinics also integrate closely with the HHST to ensure continuity of care.

Beyond homelessness, MPHN continues to invest in programs that empower people to live healthier, more connected lives. The WARATAH Program, a communityled mental health and wellbeing initiative, provides early support and connection to services for people experiencing or at risk of mental distress. It reached 2,722 participants in the past year, including 1,736 new participants.

One participant, Bruce*, from Henty, was referred for dietetic support while managing haemochromatosis, obesity, and long-term alcohol and tobacco use. With regular support and a personalised plan, Bruce* has quit smoking, stopped drinking, and lost more than 9kg. His cholesterol has improved, and he reports higher energy and a more positive outlook, saying: “I haven’t had a beer since I quit smoking, and even after I stopped taking the medication, I feel like I have so much more energy.”

WARATAH PROGRAM

5,695 occasions of service

2,722 participants supported

1,736 new participants

The Integrated Care Coordination (ICC) program supported 79 participants with 2,807 service occasions. Amy*, a 48-year-old living alone with Chronic Obstructive Pulmonary Disease (COPD) and emphysema, faced difficulties accessing healthcare due to lack of transport and financial strain.

INTEGRATED CARE COORDINATION

2,807 occasions of service

79 participants supported

HEALTH NAVIGATOR PROGRAM

95

participants supported

With the program’s support, Amy* secured a Disability Support Pension, connected with respiratory specialists, and arranged reliable community transport. “I can get to my appointments now which makes me less stressed and anxious. I’m so thankful for the coordination,” she said.

MPHN has also prioritised preventative care and education. This year, 280 occasions of service were delivered to general practices to increase knowledge and awareness around asthma and COPD, including campaigns to better support at-risk people.

ASTHMA

AND COPD EDUCATION

280 occasions of service

Delivered across Corowa, Tocumwal, and Young practices

“Promoting healthy living means working together to break down barriers.”

JANELLE DUFTY, MPHN

Vecare Health, Holbrook

Helping people Age well, stay connected, and live fully

MPHN’s work across the Murrumbidgee region is about more than services, it’s about people. Over the past year, MPHN has invested in programs that support healthy ageing, strengthen carers, and deliver compassionate palliative care, ensuring every community member can live well and with dignity.

Through initiatives such as the Vitality Passport, care finder services, and palliative care outreach, we have worked alongside residents, families, and local partners to address the challenges of ageing and end-of-life care.

The Vitality Passport, a healthy ageing program designed to help older adults stay active, connected, and independent, has been a lifeline for many across the region. In the past year, 264 participants joined the program with remarkable results: 81 percent reduced or halted frailty, 86 percent maintained or improved quality of life, and 70 percent accessed vital mental health support. Overall satisfaction averaged 4.8 out of 5.

Behind these numbers are powerful stories of change. One woman in her mid-60s, once overwhelmed by chronic pain, reduced her pain levels from nine to two and reconnected with family and community. Another participant, recovering from long COVID, shared: “I now walk each morning, exercise for half an hour, and feel ready for the day by nine o’clock.” For him, Vitality Passport was not just a program, but a pathway back to energy, connection, and routine.

In Residential Aged Care Homes (RACHs), 104 participants benefited from tailored interventions. One elderly farmer, initially withdrawn after moving into care, was gently reconnected to his history and passions. Soon, he was attending activities, sharing stories, and even inspired a poem celebrating his extraordinary life.

MPHN’s Healthy Ageing and Palliative Care Manager

Shelley Gledhill said MPHN is committed to supporting older people at every stage of life.

“Our focus is on helping seniors stay active, connected, and valued members of their communities,” Ms Gledhill said.

“We want every person to have the confidence, independence, and care they need to live their best life, no matter their circumstances.”

VITALITY PASSPORT

264 participants 81% reduced or halted frailty

8% improved or maintained quality of life 70% accessed mental health support

4.8/5 satisfaction rating

104 participants in RACHs

The Care Finder service, which helps older Australians who need intensive, face-to-face support to access aged care and community services, has further strengthened community support. A total of 316 participants received assistance through 2,453 services, ranging from health referrals to social connection programs. Marathon Health’s new referral pathway with NSW Ambulance now helps frequent non-emergency callers access appropriate support, ensuring vulnerable residents are not overlooked.

For Sandra*, a First Nations transgender woman, care finder has been transformative. Once isolated and struggling with complex health needs, she has now built trust, accessed medical and mental health support, and reconnected with community. “Care finder has been amazing… I am very grateful,” she said. Her story reflects how consistent, compassionate guidance can restore dignity and hope.

CARE FINDER SERVICES

316 participants supported

2,453 services delivered

Beyond direct services, MPHN has focused on community education and carer support, producing practical resources to empower people at every stage of life.

Guides such as Self-Care for Carers and Advance Care Planning vs. Advance Care Directive help carers and people plan and maintain wellbeing, while the Grief and Bereavement brochure and Thinking of You postcards promote support and connection.

Palliative Care Project Officer Julie Mecham said the organisation is dedicated to ensuring everyone facing the end of life receives care that honours their wishes, supports families, and respects dignity.

“Compassionate palliative care is about guidance, reassurance, and empowering people to have meaningful conversations about their care and legacy,” Ms Mecham said.

“It’s also about comfort and connection, so people feel supported during such a significant time in their life.”

Workshops delivered by the Last Days Foundation through HammondCare, help equip families with practical skills for navigating end-of-life care. Together, they help carers, families, and community members feel informed, confident, and supported, reinforcing MPHN’s commitment to compassionate, inclusive care.

COMMUNITY AND PALLIATIVE CARE

✓ New NSW Ambulance referral pathway

✓ Partnerships with ACON, Dementia Australia and Cancer Council

✓ Resources created on advance care planning, grief and bereavement

MPHN’s palliative care outreach has been extensive, focusing on equity for First Nations and LGBTQIA+ communities as well as regional populations more broadly. Aged care and palliative care staff alike have participated in local expos and senior’s forums, Dying to Know Days, and developed strategic partnerships with organisations including ACON, Dementia Australia, and the Cancer Council. Resources such as Advance Care Planning guides and grief and bereavement brochures have been distributed widely and are available online, encouraging open conversations about death, dying, and legacy.

Through these efforts, MPHN is making a tangible difference across the Murrumbidgee region. From restoring independence and social connection, to equipping carers with knowledge, and ensuring equitable access to palliative care, our work helps ensure ageing and the end of life are met with dignity, preparation, and compassion.

* Name changed for privacy.

“Compassionate palliative care is about guidance, reassurance, and empowering people to have meaningful conversations about their care and legacy.”

JULIE MECHAM, MPHN

MPHN’s Lynda Rhodes in Harden for Senior’s Week, March 2025

Building on our commitment to reCOnCiliAtiOn

MPHN’s work across the Murrumbidgee region is grounded in respect for the resilience and cultural strength of Aboriginal and Torres Strait Islander peoples. MPHN acknowledges that Closing the Gap requires walking alongside communities, listening deeply and supporting culturally safe, meaningful care.

This year MPHN has strengthened partnerships, supported community-led initiatives, and embedded First Nations voices at the heart of our work.

A major milestone was the launch of our First Nations Health Strategy, which guides work from January 2025 to July 2026. Co-designed with community voices, the strategy focuses on issues identified by Elders and local community members, including sorry business, drug and alcohol harms, food insecurity and housing.

MPHN’s Aboriginal Health and Wellbeing Manager Maxine Honeysett said the strategy also commits to strengthening partnerships with Aboriginal Medical Services, GPs and mainstream providers, alongside developing culturally safe resources.

“Our job at MPHN is to listen and to act, to make sure those voices shape the way services are designed and delivered.”

MAXINE HONEYSETT, MPHN

“We wanted to design a plan that brings together our opportunities, stakeholders and partnerships,” Ms Honeysett said.

“Our goal is for First Nations healthcare stories to be positive, which is why we’re focused on building strong, culturally safe relationships that empower our communities.”

That vision is brought to life through the services MPHN commission. The Integrated Team Care (ITC) program, delivered by Marathon Health, Griffith Aboriginal Medical Service (GAMS), Riverina Medical and Dental Aboriginal Corporation (RivMed) and Viney Morgan, continues to provide vital care coordination.

Paul*, a 54-year-old man with a cancer diagnosis, was guided through rounds of chemotherapy and immunotherapy by his Care Coordinator, who linked him with Aboriginal Health Workers, transport assistance and cultural supports. With this wraparound care, Paul’s health improved, and he has become more motivated to care for his wellbeing and reconnect with community.

INTEGRATED TEAM CARE (ITC) PROGRAM SERVICES

15,531 total services

3,909 face-to-face

11,622 via telehealth

MPHN’s Maxine Honeysett with Hope Cooper from Marathon Health

MPHN also funds targeted Alcohol and Other Drug (AOD) services. GAMS has helped young people reduce harms caused by drug and/or alcohol use or achieve abstinence and rebuild family connections. Directions Health Services, through its Pathways Murrumbidgee programs, delivers the Work it Out program which has supported participants like Josh*, who sought help to stop cocaine use and reduce alcohol intake. With counselling and case management, Josh has made meaningful progress, reporting fewer days of drinking, major reductions in drug use, and renewed optimism about returning to work. His journey shows the impact of culturally responsive, practical support.

ALCOHOL & OTHER DRUGS PROGRAMS

GAMS AOD PROGRAM

682

total participants

2,482 total services delivered

WORK IT OUT PROGRAM

94 total participants

MPHN’s role also extends to end-of-life care. In partnership with the University of Queensland, MPHN supported consultations with First Nations Elders, families and community about palliative care experiences and needs. From these conversations came Nganhayguray (Sorry) – Sorry Business, a grief and bereavement brochure designed with culturally safe language and imagery. The resource is a respectful guide for First Nations peoples during times of loss, reflecting our belief that cultural safety must be present at every stage of life.

Elders and community members are central to our work, providing cultural leadership through Welcomes to Country and taking action through local initiatives such as applying for MPHN grants. Alongside them, Ms Honeysett builds strong connections at Aboriginal Interagency meetings, Mawang Gaway Elders gatherings and visiting community hubs. Together, these efforts highlight the issues people face including rising living costs, limited outreach services and the impact of sorry business; and guide how MPHN responds.

“When we sit with community, we hear the real stories,” Ms Honeysett said.

“Communities are asking for healing spaces, for better access to services, for recognition of their strength. Our job at MPHN is to listen and to act, to make sure those voices shape the way services are designed and delivered.”

Initiatives like Yarns on the Couch, held this year in Hay, Wagga Wagga and Gundagai, gave people a platform to share experiences. These yarns not only highlight gaps but also build trust and connection, reinforcing MPHN’s commitment to community-led health.

YARNS ON THE COUCH ENGAGEMENTS

20

community members interviewed across Gundagai, Hay and Wagga Wagga

This year MPHN also achieved 80 percent of our Reconciliation Action Plan (RAP) goals, a reflection of steady progress towards embedding reconciliation into our daily work. Reconciliation is the foundation of our partnerships and our responsibility as we continue to support First Nations communities across the Murrumbidgee.

With the First Nations Health Strategy as our guide and with community voices at the centre, MPHN will continue to play its part in Closing the Gap, by supporting culturally safe services, celebrating positive stories, and working alongside communities to build stronger, healthier futures for First Nations people.

* Names have been changed for privacy reasons.

Yarns on the Couch, Deniliquin, June 2025

SUICIDE PREVENTION AND AFTERCARE: Investing in COmmunity wellbeing

This year, MPHN made significant progress in suicide prevention and aftercare across the Murrumbidgee region, strengthening support for people, families, and communities affected by suicide.

Suicide prevention continues beyond the immediate crisis. The period following a suicide attempt or suicidal crisis is a time of heightened vulnerability, where timely and coordinated care is essential to supporting recovery and can save lives.

MPHN is working with Wellways to establish the Murrumbidgee Universal Aftercare program, a service co-designed with people with lived and living experience of suicide, healthcare professionals, and community stakeholders. Once launched, it will provide proactive, person-centred support beyond hospitals, strengthening referral pathways, improving access to timely, compassionate care, and building on existing initiatives with an added focus on supporting men, children, and young people.

A key foundation for this new approach is The Way Back Support Service, which provides practical, non-

clinical support to people who have experienced suicidal thoughts or a suicide attempt. Over the past year alone, the service delivered 7,113 contacts, connecting people with timely care when they needed it most.

Amanda’s* story shows the impact of this support. After experiencing suicidal thoughts, she was promptly contacted by an Aboriginal Support Coordinator and linked with a peer worker. Over several weeks, she received flexible support, joined Wellways groups, and reconnected with her family. By the end of her time in the program, Amanda described a renewed sense of hope and shared a photo of herself with her father, saying, “I feel as though I can finally smile again.”

MPHN’s Suicide Prevention Lead Emma Bromham said significant progress has been made in preparing for the program’s opening.

Suicide prevention training, April 2025

“Consultations with the community and key stakeholders, including people with lived and living experience of suicide, identified men, children, and young people as groups needing targeted support,” Ms Bromham said.

“These insights are helping us shape Universal Aftercare so that, when launched, it delivers timely, person-centred care and stronger referral pathways.”

The importance of collaboration in this work was echoed by Wellways General Manager Zoe Evans, who said, “We are proud to partner with MPHN to deliver these critical aftercare services in the Murrumbidgee region. Every person deserves the chance to recover and reconnect after a suicidal crisis, and by working closely with communities, families, and people with lived experience, we can ensure support is timely, compassionate, and effective.”

Building community capacity is key to suicide prevention. MPHN is developing the Murrumbidgee Suicide Prevention Toolkit for Community, a practical, evidencebased resource to support local suicide prevention initiatives. MPHN, with Well Aware training, delivered free suicide prevention workshops to help people recognise warning signs, start conversations, and connect others to support, strengthening capacity and fostering safer, more connected communities.

This year the General Practice with Special Interest in Suicide Prevention activity boosted workforce capability across eight Murrumbidgee practices. Thirteen GPs and three practice nurses completed Black Dog Institute

advanced training, 50 staff undertook Recognise and Respond online training, and each practice developed a suicide-prevention quality improvement plan to strengthen support for people experiencing suicidal distress.

When a death by suicide occurs, the impact ripples through families, friends, workplaces, and entire communities. The After Suicide Support Program (ASSP), delivered by Wellways, provides emotional support, practical information, and tailored workshops to help people navigate grief and connect with local services. This year, the program delivered 809 individual support contacts and 57 group sessions attended by 1,801 participants.

Jacinta* lost her daughter to suicide in 2021, and ASSP has supported her through grief and practical challenges since. In 2023, she sought closure by viewing police photos and body cam footage from the day her daughter was found, with her support coordinator by her side. The experience was deeply emotional, and in the weeks that followed, Jacinta said she finally felt she had an ending to her story. She has since returned to casual employment and is preparing to move to a new home, with ASSP continuing to support her journey.

By investing in aftercare, training, community resources, and postvention support, MPHN is helping the Murrumbidgee region build resilience, connection, and hope, because every life matters, and every person deserves the opportunity to heal and thrive.

* Names changed for privacy.

“We are proud to partner with MPHN to deliver these critical aftercare services in the Murrumbidgee region.”

ZOE EVANS, WELLWAYS

MURRUMBIDGEE AFTER SUICIDE SUPPORT PROGRAM

809 individual support contacts

57 group sessions

1,801 participants

THE WAY BACK SUPPORT SERVICE

7,113 occasions of service

murrumbidgee mental health and AOD services expand

Across the Murrumbidgee region, MPHN continues to invest in local mental health and alcohol and other drug (AOD) services that are designed to suit the needs of each community.

A major milestone this year was the opening of two Medicare Mental Health Centres in Wagga Wagga and Young, operated by Grand Pacific Health (GPH). These centres offer free, walk-in support for people experiencing moderate to severe distress, without the need for a referral or appointment.

GPH CEO Adam Phillips said the new Medicare Mental Health Centres are helping to address a long-standing gap in regional mental health support.

“We’ve known for some time that this region in particular has great need, and so it’s really helped fill a gap,” Mr Phillips said. “We make it a really warm and friendly environment for people as well. It helps with help seeking behaviours because often it’s difficult for some people to find these services.”

MPHN’s Central Access and Navigation service ensures that when someone calls the national Medicare Mental Health number, they are connected to the right local support. This service also helps GPs and other providers navigate the mental health and Alcohol and Other Drug (AOD) system across the region.

MPHN continues to fund a range of services tailored to local needs. MyStep to Mental Wellbeing, delivered by GPH and Murrumbidgee Local Health District (MLHD), offers early intervention and psychological treatment

both face-to-face and via telehealth. One young woman in a remote area, facing complex trauma and physical health challenges, received flexible, trauma-informed support from a clinician and peer worker. Unable to access an autism spectrum disorder referral due to distance, she was connected with local services like Mission Australia and headspace. She shared: “I’ve received more care and assistance from MyStep in a short time than I had ever received from anyone in a long time.”

In the west, MyStep supported a 41-year-old man living with post-traumatic stress disorder and a psychogenic movement disorder. His condition caused painful spasms and deep depression, especially in winter. Through trauma-informed therapies, mindfulness, and cognitive behaviour therapy, he learned to manage his symptoms. In a breakthrough moment, he prevented spasms during an emotional session, something he hadn’t achieved in nine years. He expressed deep gratitude, saying that the check in calls while on the waitlist and then as follow-up made him feel less isolated and more seen.

MPHN also funds the Murrumbidgee Pathways AOD Enhancement program, delivered by Directions Health Services. This harm minimisation-based program supported 169 participants this year, offering tailored treatment and support for people and families affected by substance use.

Meeting with Jennifer Black, Mental Health Commissioner, June 2025

MEDICARE MENTAL HEALTH CENTRES

10,650 occasions of service

MYSTEP TO MENTAL WELLBEING

19,132 occasions of service

MURRUMBIDGEE PATHWAYS AOD ENHANCEMENT

169 participants supported PSYCHOSOCIAL SUPPORT

13,546 occasions of service

“We fund services that are flexible, compassionate, and locally grounded so people feel supported and empowered to take the next step in their recovery.”

ANITA MCRAE, MPHN

For people living with severe mental illness who are not supported by the National Disability Insurance Scheme (NDIS), MPHN funds Well Connected, a psychosocial support service delivered by Wellways Australia. This year, a Well Connected participant, Kylie*, connected with the service while facing addiction, homelessness risk, and serious health concerns. With support, she maintained her housing and accessed vital healthcare. Now sober and regularly engaging with her care team, Kylie has avoided further legal consequences and is working toward securing the Disability Support Pension.

Sunflower House, another psychosocial service provider funded by MPHN, supported Mandy*, a long-term participant, who joined after years of mental health challenges and hospital admissions without support. With help from staff, she secured an NDIS package and began receiving one-onone support. Despite facing major surgeries and ongoing instability, Mandy has built resilience through advocacy and community engagement. She is now preparing to volunteer in the community.

MPHN continues to strengthen mental health and AOD support across the Murrumbidgee by investing in services that are locally delivered, trauma-informed, and responsive to the needs of diverse communities. From walk-in Medicare Mental Health Centres to psychosocial and harm minimisation programs, the focus remains on making care more accessible, coordinated, and compassionate.

MPHN’s Senior Manager Priority Populations Anita McRae said MPHN is committed to building a system that works for the people it serves.

“Mental health and AOD challenges are deeply tied to people’s lives and relationships,” Ms McRae said.

“We fund services that are flexible, compassionate, and locally grounded so people feel supported and empowered to take the next step in their recovery.”

* Names changed for privacy.

Young Medicare Mental Health Centre opening, April 2025

Supporting yOung peOple through enhanced mental health services

Young people in the Murrumbidgee region are set to benefit from expanded mental health support, with headspace Wagga Wagga selected as one of 30 national sites to receive the new headspace Plus upgrade.

This enhanced model will provide specialised support for young people aged 12–25 experiencing complex mental health challenges, bridging the gap between primary care and hospital-level services.

Director of headspace Operations Wagga Wagga Shane Thomas said the upgrade will help address a critical gap in care. “headspace Plus will allow us to better respond to the ‘missing middle’, young people whose needs are too complex for standard services but not severe enough for hospital care,” Mr Thomas said.

“This uplift in capacity means faster access, more tailored support, and better outcomes.”

In the past year, headspace Wagga Wagga and Griffith supported 1,566 young people, delivering more than 10,000 direct occasions of service. Griffith also secured capital enhancement funding to renovate its site, improving the shared space with its lead agency and strengthening service integration.

Among the many young people supported this year was a Wagga Wagga client referred following the sudden loss of a close friend. The referral highlighted the urgency of the situation, and the team responded swiftly. The young person was assessed within two hours and linked to a clinician within two days. This allowed them to begin timely therapeutic support focused on grief, emotional regulation, and resilience.

HEADSPACE

1,566 young people supported

1,740 episodes of care

10,623 direct services

6,367 indirect services

headspace Griffith Centre Manager Rosanne Bisetto said the centre is committed to helping young people thrive.

“We’re here to support young people through whatever challenges they’re facing,” Ms Bisetto said.

“Our goal is to create a safe space where they feel heard, supported, and empowered to take steps toward better mental health.”

Both centres offer Alcohol and Other Drug (AOD) support programs, delivered by Directions Health Services, which provide targeted assistance for young people experiencing substance use challenges.

As demand continues to grow, MPHN remains committed to strengthening youth mental health services. The headspace Plus upgrade is a vital step forward in ensuring young people across the region receive timely, effective, and person-centred care.

Official opening of the new headspace Wagga Wagga centre, January 2025

urgent CAre access expanded in Wagga Wagga

The GP-based Urgent Care Service in Wagga Wagga is providing faster, bulk-billed access to care for urgent but non-life-threatening conditions. Developed through extensive consultation and collaboration, the service is easing pressure on the Emergency Department (ED) and delivering timely healthcare close to home for the community.

The service, established through extensive co-design and consultation, reflects strong collaboration between MPHN, local general practices, NSW Health, and healthdirect. Stakeholders across the region, including GPs, nurses, and government partners, contributed to planning workshops to ensure the service met local needs while complementing existing healthcare options.

Operating as a cooperative model across seven general practices in Wagga Wagga, the Wagga Wagga Urgent Care Service offers around 100 GP-based appointments per week for urgent but non-life-threatening illnesses and injuries. People call healthdirect on 1800 022 222 to be triaged by a registered nurse, who can book them directly into an urgent care appointment if clinically appropriate.

Healthcare at the service is fully bulk billed, providing affordable and accessible care for the community.

Operating Monday to Friday, 8:00 AM to 5:30 PM, the service complements the Wagga Wagga Base Hospital Rapid Access Clinic.

The initiative was supported by the NSW Government’s $500 million ED relief package, aimed at expanding urgent care services across the state.

Minister for Regional Health Ryan Park said the service will enable people to receive care for conditions that can be safely managed outside hospital, such as minor wounds and suspected fractures. Member for Wagga Wagga, Dr Joe McGirr, highlighted its value in reducing ED wait times.

“This is a very welcome enhancement to local health services that will improve access to care and reduce wait times for local people,” Dr McGirr said.

“By providing people with non-life-threatening conditions with quality, bulk-billed care, it will ease pressure on the ED at Wagga Base Hospital and deliver a valuable healthcare alternative to people from Wagga and surrounding communities.”

“This is a very welcome enhancement to local health services that will improve access to care and reduce wait times for local people.”

DR JOE MCGIRR MP, WAGGA WAGGA

100 GP appointments per week across

7 different general practices in the Wagga Wagga region

Dr Ayman Shenouda, Glenrock Country Practice

Investing in women’s, maternal and child wellbeing

Supporting the health and wellbeing of mothers, children, and women across the Murrumbidgee region remains a priority for MPHN. Through strategic partnerships and commissioning,MPHN is helping to deliver responsive, community-based services tailored to the needs of rural and regional families.

A standout initiative this year has been the expansion of the WARATAH for Kids program, delivered by Marathon Health. The program offers early intervention for children with developmental delays or concerns, providing access to speech pathology, occupational therapy, and paediatric health linker services. These supports are vital in ensuring vulnerable children don’t fall through the cracks while waiting for public services.

Thanks to new multidisciplinary team funding secured by MPHN, WARATAH for Kids extended its reach by onboarding five additional general practices and expanding into Lockhart, Holbrook, Tumut, Boorowa, and Wagga Wagga. These sites join existing locations in Leeton, Hay, Deniliquin, and Gundagai, with further growth planned in 2024–25. Throughout the year, 22 clinics were held and 58 children were seen.

Additional support has enabled Marathon Health to address gaps identified during the pilot phase, including improving access to therapy and strengthening service navigation for families. A dedicated Health Linker has been recruited to guide families through available supports and assist general practices. Therapy and education sessions are also being delivered to help families continue care at home.

Marathon Health Program Lead Kellie Crossley said WARATAH for Kids is a powerful example of the impact of early intervention.

“The program ensures children don’t fall through the cracks while waiting for public services,” Ms Crossley said.

Billy’s* story highlights the program’s value. Referred in late 2024 due to behavioural concerns raised by his school principal, Billy was assessed by an occupational therapist and speech pathologist, who identified developmental challenges and recommended further support. His family received strategies to use at home and school, and by May 2025, his behaviour had improved significantly. A review session with his father and teacher reinforced the progress made and outlined next steps. Billy remains on waitlists for additional services, but his family continues to advocate for him with the program’s support.

Feedback from families has been overwhelmingly positive. In a recent satisfaction survey, 100 percent of respondents agreed or strongly agreed WARATAH for Kids helped them understand the next steps for their child, listened to their concerns, and communicated with empathy. One parent shared, “He actually said he enjoyed his time with the lovely ladies so much he wanted me to rebook the appointment.”

WARATAH FOR KIDS

58 children supported across the region

22 clinics delivered

5 new general practices on-boarded

100% of surveyed parents said

They understood the next steps for their child

Staff listened to their concerns

Communication was empathetic and respectful

“With MPHN’s support, we’ve been able to expand our reach and provide families with the tools and guidance they need to support their child’s development.”

KELLIE CROSSLEY, MARATHON HEALTH

MPHN also supports mothers through the Women’s Wellness and Recovery Program delivered by Calvary, which assisted 107 participants this year under a revised model of care. Nicole*, referred by Mission Australia Family Preservation, was initially hesitant but soon engaged fully. With her case worker’s support, she reduced her alcohol intake, identified mental health as a key trigger, and attended a GP appointment. She is now pursuing further care and exploring parenting support, skill-building, and personal growth. Nicole* reports feeling stronger and more hopeful, with early progress already evident.

MPHN continues to assist Wagga Women’s Health Centre in delivering crisis support services for women. This year, the centre recorded 1,857 occasions of service, providing counselling and support for women experiencing trauma, domestic violence, and mental health challenges. One client, navigating childhood trauma and recent grief, engaged in eight telehealth counselling sessions. She learned emotional regulation, boundary-setting, and selfkindness. By the fifth session, she had returned to fulltime work, felt more confident in parenting, and reported a significant reduction in psychological distress.

For expectant and new parents, MPHN supports Gidget House Wagga Wagga, which offers free psychological counselling for those at risk of perinatal mood and anxiety disorders. This year, the service delivered 220 occasions of service. Participants have shared how the

WOMEN’S WELLNESS AND RECOVERY PROGRAM

107 participants supported WAGGA WOMEN’S HEALTH CENTRE

1,857

occasions of service

GIDGET HOUSE WAGGA WAGGA

220

occasions of service

program has helped them build confidence in parenting, establish healthy boundaries, and develop emotional coping strategies. One client reflected, “I have learned to look after myself better with learning how to put strong boundaries in place to help me be a better mum and take care of me too.”

Through these programs and partnerships, MPHN continues to help build a healthier, more resilient Murrumbidgee, supporting people of all backgrounds as they navigate parenthood and personal wellbeing.

* Names changed for privacy.

“I have learned to look after myself better.” PARTICIPANT, GIDGET HOUSE PROGRAM

Ukulele fun at Wagga Women’s Health Centre

prOviderS

Support and enhance collaboration for stronger primary care

KEY ACHIEVEMENTS:

Launched The Doctors Table dinner series and the inaugural Allied Health Forum to boost wellbeing and engagement ...page 36/40

Achieved record GP Registrar applications through the Workforce Planning and Prioritisation program ...page 36

Six new practices established and 50+ GP Registrars trained in the region ...page 36

Released the Murrumbidgee First Nations Toolkit to create culturally safe care environments ...page 36

Supported rollout of national reforms: MyMedicare, GP Aged Care Incentive, nurse-led clinics, lung cancer screening, and digital health ...page 34

90 percent of general practices registered for MyMedicare and 67 percent registered for the GP Aged Care Incentive ...page 34

First PHN in NSW to reach 50 percent general practice participation in Lumos ...page 44

Introduced individual HealthPathways logins for better workflows and Continuing Professional Development tracking ...page 45

Delivered MPHN’s first national lead clinical HealthPathways page ...page 45

27 pharmacies screened 288 people for Chronic Obstructive Pulmonary Disease/Congestive Heart Failure, referring 138 to GPs via Living Well, Your Way ...page 42

refOrming the system

As the Strengthening Medicare reforms roll out across Australia, MPHN continues to translate national policy for local impact to ensure primary healthcare providers can navigate and deliver on these initiatives.

The initial work for implementing national health reforms like registering general practices for MyMedicare has laid the foundations for subsequent initiatives including aged care and Chronic Condition Management (CCM) changes, as well as the national rollout of the new lung cancer screening program.

MyMedicare is a voluntary patient–practice registration model that strengthens continuity of primary care and MPHN has supported the implementation of the General Practice in Aged Care Incentive (GP-ACI) and CCM, and changes to the bulk billing incentives.

Wagga Wagga General Practitioner Dr Hanaa Mishricky said MPHN were central to helping her practice implement these changes.

“MPHN’s support through in person practice visits to assist with MyMedicare, supplying patient friendly materials, and helping us redesign our workflows around the new reforms has been invaluable in translating policy into practical, everyday improvements for our people,” Dr Mishricky said.

Senior Manager Primary Care Engagement Alison Jansen said almost all general practices in the Murrumbidgee region are registered for MyMedicare.

“More than 90 percent of our general practices are registered for MyMedicare and we continue to support practices requiring assistance with the patient registration options including residents in aged care homes and people accessing CCM items,” Ms Jansen said.

“To achieve this, we developed a suite of step-by-step activities for general practice to help them identify people who would benefit from MyMedicare enrolment. We also provided general practice and aged care providers with detailed information and patient resources to help them share the benefits of MyMedicare and what it means for their ongoing healthcare.

“At the end of the day, the premise of these reforms is to foster more proactive team-based care in general practice and Residential Aged Care Homes (RACHs), particularly for people with chronic conditions and complex needs

by strengthening integration across the primary care system,” she said.

To support this integration, MPHN worked closely with aged care providers and RACHs to build provider capability and address primary care workforce challenges.

MPHN’s GP-ACI Coordinator Jane Gerhard said the focus has been on helping general practice understand the GPACI initiative and what it means for aged care residents’ cycle of care.

“The GP-ACI initiative aims to encourage general practitioners to visit aged care residents in their homes, and our role has been to educate the general practice, aged care home and the residents to participate in GPACI,” Ms Gerhard said.

MPHN is also supporting a preventative health initiative around lung cancer screening, which is particularly important for people living in the Murrumbidgee where the incidence of lung cancer is higher than the NSW and national rates.

The National Lung Cancer Screening Program is Australia’s first new national cancer screening initiative in nearly two decades. Designed to detect lung cancer early, improve treatment outcomes, and save lives, particularly in under-served rural and First Nations communities, it offers free low dose CT scans every two years to high-risk, asymptomatic individuals aged between 50 and 70 with a substantial smoking history.

Leading local implementation is MPHN’s Primary Care Engagement Officer Georgina Maher who said general practitioners have been identified as best placed to identify eligible candidates for screening.

“Early detection of lung cancer can significantly improve health outcomes, so we have worked closely with general practices to build awareness of the National Lung Cancer Screening Program by sharing resources, facilitating education sessions, and supporting integration with the National Cancer Screening Register,” Ms Maher said.

“We hosted Cancer Institute NSW information sessions to ensure general practice is aware of the program,

DIGITAL HEALTH REFORM SUPPORT

In our role to support implementation of national health reform and strategies, we are working with the Australian Digital Health Agency to expand access to national platforms from general practice, into pharmacy and aged care.

“This has involved facilitating information sessions in aged care homes, and supporting My Health Record registrations and the development of security access policies,” Dr Pasupathy said.

“We also provided in-person support to 16 general practices and 14 pharmacies in 14 towns to share resources, identify barriers and deliver demonstrations.”

particularly patient eligibility requirements and we have also worked closely with Murrumbidgee Local Health District (MLHD) and our Murrumbidgee HealthPathways team to identify radiology, respiratory and oncology pathways.”

Further education support for the National Lung Cancer Screening Program through an in-person event in Leeton hosted by the Living Well, Your Way (LWYW) team presented by Respiratory Physician Associate Professor Adriaan Venter. The event was attended by 40 clinicians including local general practitioners and practice nurses.

90% of general practices are registered for MyMedicare

67% of general practices are registered for GPACI

“Our role has been to educate the general practice, aged care home and the residents to participate in GP-ACI.”

JANE GERHARD,

MPHN

GPACI visit Vecare, Holbrook, 2025

Strengthening collaboration and engagement with gener Al pr AC tiCe

MPHN continues to foster its more than 30 years of support for general practice through a range of initiatives including commencing a new GP engagement event, addressing workforce challenges through the Workforce Planning and Prioritisation initiative, and launching a new First Nations GP Toolkit.

Throughout the year, MPHN continued its focus on strengthening engagement and collaboration with primary care clinicians and staff.

In August 2024 MPHN launched a new initiative, The Doctors Table, to bring doctors together for dinner and conversation. Doctors Table events have been held in Griffith, Finley, Cootamundra, Wagga Wagga and Tumut with more than 40 general practitioners attending.

MPHN’s firsthealth Board Chair Dr Jodi Culbert said the initiative provides the opportunity for general practitioners to relax after work with colleagues and to discuss local challenges and opportunities

“As a busy GP, I know firsthand the complexities for GPs to take time out of our busy schedules and connect with each other,” Dr Culbert said.

“GPs are the coalface of the emerging health needs for our communities, and what might be impacting one town, may not be an issue in another, or it could be an issue and sharing solutions can help foster new ideas and thinking.” During conversations, MPHN has heard on the

ground perspectives across a range of areas including the national health reform initiatives, workforce challenges, multidisciplinary models of care and digital health and the introduction of AI in healthcare.

While workforce challenges are longstanding for rural and regional practice, MPHN has been working to support long-term workforce development and stability through implementing the GP Workforce Planning and Prioritisation (WPP) program.

Two local GP Advisors – Drs Elizabeth Campbell and Rachel James – were central in supporting WPP stakeholder engagement, data validation and departmental reporting against the newly developed GP Training National Assessment Tool by the Department of Health, Disability and Aged Care.

Dr Rachel James said local stakeholder engagement with clinicians, healthcare professionals and the local community has been pivotal.

“As a team, we have engaged many stakeholders to better understand workforce challenges and gaps, and used

The Doctor’s Table, Wagga Wagga, May 2025

data to identify the region’s priority catchments, and to map current local training pathways and opportunities for improvement, all of which will help training and career planning for prospective general practitioners to our region,” Dr James said.

“The inclusion of real-world experience and qualitative insights gained through our many stakeholder engagement activities, and being able to showcase these locations as great places to live and work were critical validation steps and will help guide placement decisions for the Royal Australian College of General Practitioners (RACGP) and Australian College of Rural and Remote Medicine (ACRRM).”

It is anticipated the 2026 GP Registrar applications for the Murrumbidgee will be higher than previous years.

Indeed, engagement and collaboration with general practice are key to strengthening our support initiatives. For example, to further strengthen GPs and general practice staff create culturally safe and inclusive environments for First Nations people, MPHN launched the Murrumbidgee First Nations Toolkit for General Practice in December 2024.

The toolkit empowers healthcare providers to create spaces where First Nations people feel safe, valued and respected and covers topics such available programs and services, practice workflows, patient journeys, Murrumbidgee HealthPathways, and the First Nations health workforce.

MPHN Aboriginal Health and Wellbeing Manager Maxine Honeysett said culture plays a vital role in healthcare decisions for First Nations peoples, making it essential for providers to offer care that is respectful and well informed.

“The toolkit makes it easy for practices to ensure they’re providing the best possible service for their First Nations people and helping to improve health outcomes for the community,” Ms Honeysett said.

In addition to promoting localised resources like the First Nations GP Toolkit, business as usual work continues to be valued by general practice.

NEW PRACTICES FOR THE REGION!

Congratulations to the following practices that have recently opened. MPHN is proud to support you, including recruitment and accreditation, and look forward to continuing to support your practices.

Ralifah Medical Centre, Griffith Driver Medical Centre, Griffith Culcairn Mediclinic, Culcairn Doctors@Tocumwal, Tocumwal ISRA Medical Services, Young Marsden Street Medical Practice, Boorowa

Senior Manager Primary Care Engagement, Alison Jansen said MPHN’s strong established relationships with the region’s 94 general practices underpins the team’s ability to provide 1,142 visits in a 12-month period.

“Given our large geographic region, almost half of the practice visits were made in person, and we know that primary care staff appreciate this level of personal engagement,” Ms Jansen said.

“The visits cover a range of topics and support from quality improvement to MyMedicare and health reform initiatives, immunisation advice, digital health and with the opening of six new practices, accreditation assistance was a priority.

Professional development opportunities were also available with MPHN holding 41 Continuing Professional Development (CPD) events, and we welcomed 50 GP registrars and five University of Wollongong medical students undertaking their training in the Murrumbidgee.

“Connecting undergraduates, GP registrars and the local health workforce is crucial to fostering a rewarding work and social experience with the aim of Murrumbidgee being a place of choice for future doctors,” Ms Jansen said.

“What might be impacting one town, may not be an issue in another, or it could be an issue and sharing solutions can help foster new ideas and thinking.”

DR JODI CULBERT

Fresh ideas to support Aged CAre prOviderS

MPHN is empowering Residential Aged Care Homes (RACHs) with clinician-led input to a range of initiatives.

By supporting health reform implementation, convening a dedicated provider forum, boosting telehealth capability and capacity, and streamlining communication between Residential Aged Care Homes (RACHs), general practice and hospitals, MPHN is helping to enhance aged care provider connection, workflow efficiencies, and care for residents.

As part of the General Practice Aged Care Incentive (GP-ACI) health reform initiative, MPHN commenced practice nurse-led clinics in thin markets. The goal is to improve access to primary healthcare in areas with limited services. The clinics support sustainable care models in rural, remote, and under-served communities. MPHN was one of 18 PHNs selected for this funding. Work is continuing to explore how these clinics can strengthen aged care and support general practice in thin markets.

MPHN’s GP-ACI Coordinator Jane Gerhard said the region’s model of care for the thin markets funding was designed by local clinicians and providers to meet the needs of the local aged care system.

“Through co-design, we met with five general practices and six RACHs. We held an additional consultation session attended by another two general practices and two health service organisations to further refine the model,” Ms Gerhard said.

“What was designed was a model where practice nurses are working to their top of scope by running dedicated clinics at the RACHs which provides an additional layer of support for both the residents and the general practitioner and wider healthcare providers involved in that person’s care.

“Seven practice nurse clinics have been established which are increasing access to planned primary healthcare for aged care residents in locations where it’s hard to access care. General practice is already seeing great benefits around increased care planning and vaccinations. This is a direct result of the practice nurse clinics.”

One practice implementing these clinics is Your Health Griffith. Practice Manager Rosie Harriman said the practice would not have been able to support an aged care home in Hillston, some 110 kilometres away without funding from the Thin Markets initiative.

“We would not have the resources to send a nurse with Dr DeMarco on her outreach visits to support Lachlan Lodge residents in Hillston without the thin markets grant made possible through the aged care team at MPHN,” Ms Harriman said.

As part of MPHN’s continuous improvement, a survey to all RACHs was disseminated to understand issues, challenges and opportunities with its approach to supporting aged care health reform implementation locally.

MPHN’s Healthy Ageing and Palliative Care Manager Shelley Gledhill said the survey, in which 72 percent of RACHs completed, identified opportunities for MPHN to enhance support with processes and training.

“Streamlining communications between RACHs, general practitioners and hospitals was identified as a gap, so the team worked with the RACHs, GPs and the Murrumbidgee Local Health District (MLHD) to redesign the ISBAR form, which stands for Introduction, Situation, Background, Assessment and Recommendation, and then provide communication training and support for its use. The ISBAR form helps better articulate the situation for the patient and creates efficiencies as the resident moves between care settings,” Ms Gledhill said.

“We also provided training to aged care professionals about the MPHN/MLHD Acute Care Decision Guidelines.”

To support aged care providers from across the region connect, network and stay up to date with training opportunities and reform updates, MPHN operates a virtual community of practice and an online team collaboration space through Basecamp.

In May, aged care providers and professionals gathered in Deniliquin for the 2025 Murrumbidgee Aged Care Forum, hosted by the Murrumbidgee Aged Care Consortium, MPHN, and Charles Sturt University’s Three Rivers Department of Rural Health. The forum was a chance to acknowledge the work occurring across the region and reflect on how aged care services are adapting to meet changing needs, policy reforms, and community expectations.

“We know the aged care workforce has been under immense pressure in recent years, yet local providers

continue to show incredible resilience and commitment. This forum was about taking the time to say thank you, celebrate the innovation we’re seeing, and ensure aged care professionals feel supported,” Ms Gledhill said.

“Events like this remind our aged care teams that they’re not alone; there’s a whole network of peers, organisations and leaders working alongside them to shape a stronger future. And, it’s clear regional aged care providers are doing extraordinary work, but when they’re given the space to connect, share and be recognised, the whole system becomes stronger.”

HEALTHY AGEING TELEHEALTH PROJECT

WRAPS UP

Between June 2023 and December 2024, 37 Residential Aged Care Homes (RACHs) participated in the Healthy Ageing Telehealth Project, out of which 15 homes received telehealth funding, and 22 homes saw the portable telehealth equipment installation and training for staff to allow residents, and their carers to connect to virtual medical care.

MPHN facilitated the Telehealth funding, Telehealth equipment set-up and training. RACHs also had access to telehealth education through a microsite and could contact the team for troubleshooting help.

MPHN’s digital health team also facilitated four information sessions on My Health Record, e-Prescription, Active Script List and My Health App with RACHs.

Murrumbidgee Aged Care Forum, Deniliquin, May 2025

Primary health AllieS

Allied health is gaining increased attention from government particularly through key primary care reform initiatives and reviews such as Strengthening Medicare, National Primary Care 10-year Plan and Scope of Practice Review – and Primary Health Networks play a critical role in enabling these reforms especially in how they support and integrate allied health services.

Despite their essential role in primary health, allied health professionals often work in isolation, across fragmented systems and with demanding workloads that leave little room for professional connection. And while local communities and people deeply value their care, much of what happens behind clinic doors goes unrecognised on a broader scale.

Determined to change that narrative, MPHN has continued to implement a range of strategies to strengthen its support for its more than 500 allied health professionals and 200 practices across the region, including establishing an advisory committee, developing an Allied Health Engagement Strategy and hosting the inaugural Murrumbidgee Allied Health Forum.

Attended by almost 50 of the region’s allied health professionals, the forum’s special guest was Chief Allied Health Officer Anita Hobson-Powell who reflected on the theme Now and Next in her welcome address.

MPHN Allied Health Engagement Lead, Renelle Harrison, said the forum acted as a celebration of the innovation, resilience and excellence that defines rural allied health practice.

“In a system that carries high clinical workloads and often a sense of isolation as practitioners, the chance to connect

in person and celebrate the rural allied health workforce was incredibly valuable,” Ms Harrison said.

“There was so much positive discussion and blue sky thinking alongside practical examples of what’s already working well in our region. We heard about longstanding programs that are steadily growing and increasing in capacity, as well as fresh ideas that have a really bold vision. I think we need both to support a strong future.”

Speaking at the conference MPHN’s firsthealth Board Chair Dr Jodi Culbert said her background as a physiotherapist prior to being a general practitioner helps her to understand the challenges and opportunities for allied health professionals to be involved in supporting multidisciplinary team care approaches.

“For me, multidisciplinary team care or MDT can take many forms. It’s not always about having allied health co-located in general practice for example. It’s about promoting access to person-centred care, through choice and highly skilled and specialised, preventative, equitable, and wellbeing-focused services,” Dr Culbert said.

“Looking ahead, there is a growing focus on building capacity for innovative, MDT models of care - enabling all clinicians to work to the top of their scope. Leaning into these opportunities as they arise over the coming years

Allied Health Forum, July 2025

will see allied health well-positioned to strengthen valuebased care in primary health settings.”

The content of the forum was closely aligned with the insights provided by the Murrumbidgee Allied Health Advisory Committee, which held its first meeting in December 2024 after a robust recruitment process. The nine committee members represent a range of allied health professions practising across the region.

“Our Allied Health Advisory Committee provides strategic advice to MPHN to support the development of a sustainable allied health engagement function within the region,” Ms Harrison said.

“I would like to take this opportunity to thank each of our committee members for their enthusiasm and advice to support localising and implementing the National PHN Allied Health in Primary Care Engagement Framework, ensuring national strategies are adapted to suit local needs.”

Specifically, the committee played a central role in developing MPHN’s Allied Health Engagement Strategy 2025-2027, which was published in April 2025, and

subsequently informed the development of a tailored communication plan to optimise reach and engagement with the region’s wider allied health practitioners.

“As we have moved to implement the two-year strategy, some activities already underway include improving allied health representation among MPHN’s Governance structures such as the clinical councils,” Ms Harrison said.

“We are working to support workforce pipelines and professional development. Interested practices have received tailored digital maturity assessments and individualised action plans, and integrated care is being advanced through inclusion in Murrumbidgee HealthPathways and promotion of multidisciplinary models of care.

“We have also expanded on the resources available to allied health via our website, including the National Allied Health Practice Engagement Toolkit, and a range of links to general supports for allied health professionals and practices such as information on scholarships and further education, digital health resources, practitioner support and wellbeing, and student support,” she said.

“Our Allied Health Advisory Committee provides strategic advice to MPHN to support the development of a sustainable allied health engagement function within the region.”

RENELLE HARRISON, MPHN

MURRUMBIDGEE ALLIED HEALTH ADVISORY COMMITTEE MEMBERS

Claire Lawson (Chair, physiotherapist)

Cassandra Mullins (occupational therapist)

Ellen McMaster (physiotherapist

Josh Jones (exercise physiologist)

Lauren Barrett (psychologist)

Leanne Baulch (dietitian)

Mina Malek (pharmacist)

Thomas Ford (optometrist

Zoe Hughes (social worker)

Alison Jansen, Renelle Harrison, Anita Hobson-Powell, and Narelle Mills at the Allied Health Forum, July 2025

pHArmACiSt S at the frontline of early detection

A pharmacy-based screening program is helping to detect chronic disease earlier in the Murrumbidgee region, supporting better outcomes for people and strengthening collaboration between providers.

In rural communities, where access to healthcare can be limited, community pharmacists are stepping into a new role — one that is helping to detect chronic disease earlier and connect people to the care they need.

The Pharmacy Screening Program, part of the Living Well, Your Way (LWYW) initiative, is demonstrating how pharmacists — as trusted, accessible health professionals — can play a vital role in identifying early signs of chronic disease and referring people to general practice for timely diagnosis and management.

MPHN’s LWYW Community Pharmacist Kym Ramsey said the program is helping pharmacists play a more proactive role in early detection and strengthening links with general practice.

“Pharmacists are often the first point of contact for people experiencing symptoms,” Mr Ramsey said.

“By equipping pharmacists with the tools and training to screen for chronic disease, we’re supporting early detection and strengthening the connection between pharmacy and general practice.

“Pharmacists told us they value the opportunity to contribute more directly to patient care and appreciate the support from the LWYW team and the chance to work more closely with local GPs.”

Following a successful pilot in 2023–24, the program expanded in the 2024–25 financial year to include 27 pharmacies across the Murrumbidgee region. Between July 2024 and June 2025, 288 people were screened — 200 for Chronic Obstructive Pulmonary Disease (COPD) and 88 for Congestive Heart Failure (CHF). Of those screened, 138 people were referred to their GP for further assessment, including 94 for COPD and 44 for CHF.

The program is reaching people who may otherwise fall through the cracks. Almost 75 percent of participants had not recently consulted their GP about their symptoms, and many were unaware their symptoms could be linked to a chronic condition. Pharmacists used screening tools, including micro-spirometry for COPD, to assess risk and refer people to their nominated GP. The service was provided at no cost to people.

The impact of the program is best illustrated through the stories of people like Edith, an 82-year-old woman who visited her local pharmacy seeking relief for breathlessness. During the screening, the pharmacist identified symptoms consistent with heart failure and referred her to her GP. Further testing confirmed a diagnosis of CHF — a diagnosis that may have otherwise been delayed.

Mr Ramsey said stories like Edith’s are a reminder of how timely intervention can change the course of someone’s health journey.

“We often hear from pharmacists that people are surprised to learn their symptoms could be something more serious,” Mr Ramsey said.

“Being able to identify those chronic disease symptoms earlier and connect people to care can make a real difference — not just in preventing hospitalisation, but in improving someone’s quality of life.”

These experiences also reinforce the value of pharmacists as part of the broader care team.

“Pharmacists feel empowered by the opportunity to contribute more directly to patient outcomes and to work in closer partnership with general practice,” Mr Ramsey said.

The Pharmacy Screening Program was co-designed with local pharmacists and GPs to ensure it could be integrated into pharmacy workflows and support continuity of care, and includes training and upskilling opportunities.

“Pharmacists utilising the program receive training in COPD and CHF screening, including the use of microspirometry devices, and are supported with referral templates, decision trees and cultural awareness resources’” Mr Ramsey said.

“Participating pharmacies are also provided with program payments to support their involvement, recognising the time and expertise required to deliver the service.”

An independent evaluation of the Pharmacy Screening Program is currently underway by Human Capital

Alliance, with results expected in October 2025. The findings will help shape future directions and support continuous improvement. Funding for the program has been extended to November 2025, allowing more people to benefit from early detection and timely care.

“Programs like this show what’s possible when we invest in local solutions and support providers to work together,” Mr Ramsey said.

“We’re hopeful the evaluation will demonstrate the value of this model and support its continuation.”

The Pharmacy Screening Program is part of LWYW, a collaborative initiative that supports people to live well in their community by improving access to care and strengthening local health partnerships. Delivered by MPHN in partnership with Murrumbidgee Local Health District (MLHD) and funded by NSW Health, the initiative is designed to empower communities and providers to work together to improve health outcomes.

“Programs like this show what’s possible when we invest in local solutions and support providers to work together.”

KYM RAMSEY, MPHN

288 people screened across 27 participating pharmacies

200 COPD and

88 CHF

138 referrals made to GPs for further assessment

94 COPD and 44 CHF

by Human Capital Alliance, with results due October 2025

MPHN’s Kym Ramsey with local pharmacists

digitAl HeAltH

drives system change and transformation

Primary health services across the Murrumbidgee are harnessing digital tools and data to modernise care, improve outcomes, and build a more connected, efficient health system, marking a pivotal shift in how care is designed and delivered.

MPHN’s digital health team continues to strengthen the region’s digital maturity by supporting primary healthcare providers across the region to implement digital health action plans and to connect to various electronic health platforms and systems.

Following MPHN’s region wide Digital Health Maturity Assessment in early 2024, where 148 organisations, including aged care, allied health and general practice underwent a personalised assessment, 33 organisations were identified as having a foundational level of digital maturity.

MPHN’s Digital Health Lead Dr Vimal Pasupathy (PhD) said MPHN has supported organisations to raise their digital maturity based on a customised action plan.

“We have worked to support those organisations at the foundational level to build their capacity and capability for digital health in areas such as cyber-security, telehealth, My Health Record, Provider Connect Australia, Electronic Practice Incentive Payments, and Disaster Recovery,” Dr Pasupathy said.

“The goal is to improve the digital health maturity of these foundational organisations to elevate them before MPHN develops a dedicated region-wide digital health strategy.”

Jerilderie Medical Centre general practitioner Dr Assem Swaid said in a small-town setting such as Jerilderie,

timely access to a patient’s health information is crucial for effective clinical decision making.

“My Health Record supports continuity of care by enabling practitioners to view a patient’s medical history, whether they are long-term residents or visiting. Accessing a patient’s health summary during consultations allows for more accurate, informed decisions and ensures that other healthcare providers can review and build upon the care provided,” Dr Swaid said.

“Recently, our staff received training on several digital health initiatives that further enhance our ability to deliver consistent, high-quality care. The support and training provided have been invaluable in helping us maintain the highest standard of care for our community and surrounding areas.”

MPHN is now a business partner of Provider Connect Australia (PCA), enabling general practices and pharmacies registered with PCA to update their business information on a shared platform accessible to other business partners including MPHN. Almost 40 percent of general practices, and just over 30 percent of pharmacies across the Murrumbidgee region are registered with PCA.

“Business information sharing initiatives like PCA will allow us to better support primary healthcare providers and can lead to improved health outcomes,” Dr Pasupathy said.

MPHN MAKES LUMOS HISTORY!

MPHN is working with NSW Health to support general practice participation in the Lumos initiative, a state-wide data linkage program that securely combines de-identified general practice data with hospital and other health system data to help understand the patient journey across healthcare settings.

For the first half of 2025, MPHN was identified as the first PHN in NSW to reach more than 50 percent of general practice participation in Lumos, with 52.6 percent – up by 8.2 percent from the six months prior.

Empowering clinicians with lOCAliS care pathways

From individual logins, to leading its first national clinical page, Murrumbidgee HealthPathways is supporting health professionals to care for their people.

The Murrumbidgee HealthPathways team developed and reviewed 136 HealthPathways pages and successfully delivered two major projects; moving from shared to individual logins, and leading the creation of a national vulvovaginal candidiasis page for the New South Wales sexual health suite.

Not only does Murrumbidgee HealthPathways continue to support clinicians when managing their people at the point of consultation, but the shift to individual logins also supports their learning and development goals with tracking of Continuing Professional Development (CPD).

HealthPathways Manager, Olivia D’Souza said the team of five clinical editors are proud of the significant contribution they have made to supporting their colleagues across the region.

“Lead Clinical Editor Dr Sally Johnson worked closely with the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) and our NSW HealthPathways colleagues, to lead the national development of vulvovaginal candidiasis page to support with assessment and management,” Ms D’Souza said.

“Being able to lead the development of a national page like this firmly places the Murrumbidgee team as highly skilled and capable of such work.”

In addition, almost 100 clinical and request pages around mental health and suicide prevention were reviewed or developed.

Clinical Editor Dr Elizabeth Campbell said the team worked closely with local health partners such as Murrumbidgee Local Health District (MLHD), psychiatrists, pharmacists and nurses to ensure pages included up-to-date clinical information and were localised appropriately.

and discussions, we were able to find gaps in content and better understand what healthcare professionals need to support their people.”

DR ELIZABETH CAMPBELL, CLINICAL EDITOR

“For example, we learned clinicians were looking for more details and information on conditions and resources at the point of consultation such as clozapine monitoring and mental health literacy.”

Significant work developing and updating the violence, abuse and neglect suite was also achieved.

“The team published 11 pages, to support clinicians with people who are experiencing domestic family violence, sexual assault and to support child protection and wellbeing,” Ms D’Souza said.

“For the first time we also created pages specifically to support nurse consultations for wound management, publishing seven clinical pages and two request pages.”

At its heart, Murrumbidgee HealthPathways is the local clinical community supporting each other and their people, and with almost 600 localised pages, the platform provides healthcare teams with assessment, management and referral advice at the point of care.

Murrumbidgee HealthPathways team members Toni Preuss, Senior Manager Integration, HealthPathways Manager Olivia D’Souza, and Lead Clinical Editor Dr Sally Johnson

Primary health CHAmpiOnS recognised

The 2024 Primary Healthcare Awards in Wagga Wagga on Friday 1 November and included a new award category of Emerging Leader.

The 2024 Primary Healthcare Awards highlighted the remarkable achievements of healthcare leaders and community organisations from across the region.

MPHN’s firsthealth Board Chair Dr Jodi Culbert said it was a pleasure to recognise the outstanding achievements in primary healthcare through the awards.

“Every time, we are just impressed by how worthwhile it is to see people’s work showcased, whether as finalists or nominees,” Dr Culbert said.

“Health professionals aren’t always very good at selfpromotion, self-recognition, sometimes self-care. But when you take the time to put on paper the things that you do, the things that you’re proud of and passionate about, and we get to read them, it’s just incredibly encouraging.

“On behalf of the Board, I extend heartfelt congratulations to this year’s award recipients and finalists. I hope you’re inspired by each other tonight to keep doing all the great work you’re doing for our community.”

Outstanding Contribution to Leadership in Primary Healthcare award winner Riverina Medical and Dental Aboriginal Corporation (RivMed) received their accolade after overcoming workforce challenges by successfully recruiting three full-time registrars, two of whom have

become Fellows, and training Junior Medical Officers (JMOs) through Murrumbidgee Local Health District (MLHD). This initiative offers meaningful placements and valuable general practice and Aboriginal health experience, which encourages interns and registrars to stay in rural practice.

RivMed’s Dr Rachael Fikkers Senior Medical Officer accepted the award thanked MPHN for its support and said, “I think that this is a really important sort of recognition of the important work that we do at RivMed. It’s been a challenging few years. It’s just a testament to the staff and the collegiality that we have, and amazing leadership with our CEO, Peta Larsen.”

The inaugural category of Emerging Leader was won by Cristie Simpson for her role as an Allied Health Assistant in the Griffith Aboriginal Medical Service (GAMS) pilot speech therapy program with the Rural Doctor’s Network to support local First Nations children. Ms Simpson said it had been a wonderful journey to re-establish speech therapy services at GAMS.

“I would like to thank our management and staff and the Rural Doctors Network and speech pathologist Michaela Thompson, who have all been an absolute pleasure to work with to create this program for the children in our community,” Ms Simpson said.

Murrumbidgee Primary Healthcare Awards, November 2024

Deniliquin LHAC launched its Health in Your Hands project to address health needs in the Edward River Local Government Area, which saw them take out the Promoting Health Living award. The 12-month project delivered repeated messaging on how lifestyle changes such as nutrition, exercise and smoking cessation, can prevent or reduce chronic disease risks. Anecdotal feedback indicates participants are engaging positively and believe that committing to lifestyle changes can improve health outcomes.

On accepting the award, Deniliquin LHAC Chair Lynda Barclay said “I’d like to thank MPHN for providing the grants. We know our community, we know what they need.” Ms Barclay said.

The Innovation award went to Instrumental Swallow Assessment Service, Collaborative Health Murrumbidgee. The mobile service addresses geographic barriers by using a portable fibreoptic endoscopic device – reducing wait times and client costs, and likely lowering hospital admissions related to aspiration complications. The program also provides free educational support through clinics for GPs and Residential Aged Care Homes (RACHs) to enhance dysphagia competencies.

Einasleigh Happer said the service was passionate about delivering exceptional speech pathology across the Murrumbidgee.

“It’s grown very quickly over that time. We spend a lot of time and money travelling to learn new skills that we can’t access in Australia as private practitioners, so it’s very exciting, but without funds, it’s pretty tricky to do much about it. So, thank you very much,” Ms Happer said.

The Murrumbidgee Men’s Group’s Lived Experience Presentations took out the Murrumbidgee Community Grant of the Year. Utilising a Murrumbidgee Suicide Prevention Community Group Grant, the lived experience talks to community groups saw speakers share their personal experiences, discussed identifying triggers and warning signs, and provided strategies for staying well and seeking help to inspire hope and highlight the importance of mental wellness and recovery.

Murrumbidgee Men’s Group member Craig Maxwell said it was great to see mental health being talked about.

“To see the change in men from the first time they rock up to the group, the amount of confidence that it builds, the social connection that it has, and some of the stories of resilience that they share is really empowering,” Mr Maxwell said.

“Every time, we are just impressed by how worthwhile it is to see people’s work showcased, whether as finalists or nominees.”

DR JODI CULBERT

AWARD WINNERS AND FINALISTS

OUTSTANDING CONTRIBUTION TO LEADERSHIP IN PRIMARY HEALTHCARE

Winner: Riverina Medical and Dental Aboriginal Corporation (RivMed)

Highly commended: Peta Cullis

EMERGING LEADER

Winner: Christie Simpson

Highly commended: headspace Griffith CARES team

INNOVATION

Winner: Instrumental Swallow Assessment Service, Collaborative Health Murrumbidgee

Finalist: APLUS Pharmacy Education

Finalist: Guunu-Maana (Heal) Community Coordinated Burn Care

PROMOTING HEALTHY LIVING

Winner: Health in Your Hands

Finalist: Dr Trudi Beck – Mums and Bubs

MURRUMBIDGEE COMMUNITY GRANT OF THE YEAR

Winner: Lived Experience Presentations, Murrumbidgee Men’s Group

Highly commended: Healthier Together in Deni

Finalist: Active Farmers Hillston Wellness Day

Lead and inspire for positive impact innOvAtiOn

MPHN presented new research on chronic disease and homelessness at national forums, informing rural health policy ...page 56 KEY ACHIEVEMENTS:

The Diabetes Regional Education, Access and Management Outreach Clinic delivered specialist diabetes care to 164 people in 13 rural towns, reducing barriers to management ...page 50

More than 87 percent of participants in the Diabetes Australia multicultural education project reported increased diabetes knowledge ...page 50

31 general practices supported 785 people with chronic disease care, positively impacting hospital and Emergency Department costs ...page 52

Living Well, Your Way’s Summer Strategy nurse-led clinics across 18 practices cared for 252 people, with 78 percent booking follow-ups and 59 percent referred for extra support ...page 52

The A Systems-Approach to Enhancing Community-Based Medication Review (ASPIRE) trial enrolled 280 participants, credentialed 17 pharmacists, and hosted two professional development events to improve medication safety ...page 56

The Strengthening Care 4 Rural Children program supported 56 GPs across 10 practices, delivering more than 300 paediatric appointments ...page 54

diAbeteS OutreACH changing lives

The DREAM Diabetes Outreach Clinic is transforming diabetes care in the Murrumbidgee. By bringing specialist support directly into rural towns, the program is reducing barriers to care, empowering local clinicians, and improving health outcomes for people living with diabetes.

DREAM, which stands for Diabetes Regional Education, Access and Management, launched in February 2024 as a partnership between St Vincent’s Hospital Sydney, MPHN and Murrumbidgee Local Health District (MLHD), thanks to support from the St Vincent’s Curran Foundation. In the past year, the program supported 164 people across 13 rural and regional towns, from Tumut and Gundagai to Hay, Griffith and West Wyalong.

For MPHN, the initiative reflects a core organisational Strategic Focus Area: leading innovation and inspiring for positive impact. MPHN CEO Stewart Gordon said diabetes is one of the most pressing health challenges facing our region.

“The Murrumbidgee has one of the highest diabetes prevalence rates in NSW, and our hospitalisation rates are higher than the state average,” Mr Gordon said.

“DREAM is about meeting that challenge head-on. We’ve worked with our partners to design a model that fits the realities of rural life, removes barriers to specialist care, and empowers people to manage their health with confidence.”

For many people in the Murrumbidgee, specialist care has traditionally meant hours of travel and long waitlists, a barrier that often delays treatment or makes it inaccessible altogether. DREAM changes that by bringing specialists directly into local communities. The DREAM team, made up of endocrinologists, diabetes educators and allied health professionals, delivers face-to-face consultations in general practices across the region. People receive tailored education and management plans, followed by telehealth appointments six months later to check progress and provide ongoing support.

“It really is a dream,” said St Vincent’s Health Network Sydney Diabetes Clinical Nurse Consultant Gael Holters.

“Being in the Murrumbidgee is helping us better understand the unique challenges and needs of rural communities in managing diabetes, but equally important is people having equity of service with their city cousins.”

Dr Nèle Lenders, Endocrinologist and Diabetes Specialist from St Vincent’s Hospital Sydney, said sharing the consultation with local GPs and their people was beneficial for everyone.

“These consultations allow us to educate GPs on the latest developments in diabetes medication and care,” Dr Lenders said.

“At the same time, we gain valuable insights from the GP about the challenges and limitations their people face. This collaboration helps us tailor our care to suit the resources and access available locally.”

While the clinics deliver vital care for people, they also provide education and professional development for GPs, nurses and practice staff. By consulting alongside local practitioners, DREAM specialists share knowledge on treatments, medications and best practice in diabetes management. This builds skills within local practices, ensuring benefits extend well beyond the clinic days themselves.

People attending the DREAM clinics have reported improvements in blood glucose control, weight management and overall confidence in managing their condition. For many, it is the first time they’ve had access to a specialist consultation without the cost and disruption of travelling to a major city.

The DREAM initiative is only possible through strong partnerships and a shared commitment to equity in healthcare. MPHN has played a central role in leading the local implementation, working with practices to host clinics, coordinating outreach visits, and ensuring the program responds to community needs.

“The DREAM Diabetes Outreach Clinics are a great example of how MPHN is leading innovation for positive impact,” Mr Gordon said.

“This project has shown what is possible when innovation, collaboration and local leadership come together –healthier communities, closer to home.”

IMPROVING DIABETES MANAGEMENT

THROUGH EDUCATION

MPHN commissioned Diabetes Australia to deliver a diabetes education project for multicultural communities and health professionals within the Griffith region.

The overall aims of the program were to achieve sustainable improvements in diabetes management and community knowledge. For culturally diverse communities, the specific aim of the education sessions was to enhance the community’s knowledge of diabetes and improve health outcomes.

Project implementation included engagement with relevant local community organisations, services, leaders and members of local multicultural communities.

More than 87 percent of participants reported to have increased their level of knowledge on diabetes management.

164 people across 13 rural and regional towns, from Tumut and Gundagai to Hay, Griffith and West Wyalong

DREAM Wagga Wagga clinic,May 2025

DREAM Griffith clinic, November 2024

A breath of fresh CAre

A collaborative model is transforming chronic disease management across the Murrumbidgee, and this year helped more than 7,500 people across 18 activities breathe easier and live better in their communities.

In the Murrumbidgee, a quiet revolution in healthcare is progressing. The Living Well, Your Way (LWYW) initiative, a joint initiative between MPHN and Murrumbidgee Local Health District (MLHD), is transforming chronic disease care. Focusing on collaboration and innovation, the program shows geography shouldn’t limit health.

Part of NSW Health’s Collaborative Commissioning program, LWYW integrates public and private acute, community and primary care providers under a unified model. It aims to improve services for people with chronic conditions such as Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF), focusing on early intervention and fewer hospitalisations.

MLHD’s LWYW Program Director Caroline Holtby said the co-designed model has delivered strong results for the 2024–25 financial year.

“LWYW is about creating a one-system approach for people and making healthcare more connected, responsive and equitable,” LWYW Program Director Ms Caroline Holtby said.

One of the program’s standout achievements was the 2024 Winter Strategy, which supported 785 people across 31 general practices. With an investment of just $327 per patient, the program delivered proactive care reducing hospital and Emergency Department (ED) visits, less than half the cost of one ED visit.

MPHN’s LWYW Senior Project Officer Kelly Dal Broi said people received support including GP Management Plans, immunisations, spirometry and Sick Day Action Plans.

“The program also improved staff capability, with 97 percent of surveyed clinicians feeling more confident managing chronic illness. Winter Strategy is a practical example of how investing in primary care can ease pressure on hospitals and improve patient outcomes,” Ms Dal Broi said.

MPHN’s LWYW Practice Nurse Program Officer Elise Penton said building on the success of Winter Strategy was the Summer Strategy initiative which piloted nurseled chronic disease clinics from October 2024 to May 2025.

“Summer Strategy was developed in response to rising chronic disease rates and workforce pressures. The program enabled nurses to lead care for diabetes, respiratory disease and heart failure,” Ms Penton said.

“Eighteen general practices participated, and more than 250 people attended 106 nurse-led clinics, with nearly four in five booking follow-up appointments and more than half referred for extra care. Summer Strategy has shown that when nurses are supported to work to their full scope, people benefit from more accessible, proactive care.”

As part of LWYW, MPHN partnered with the Lung Foundation Australia to offer training scholarships and grants to support Lungs in Action classes at no cost to participants. Nine providers were trained, and six fully funded programs are filling a critical gap in postrehabilitation support for people with chronic lung and heart conditions.

The program offers safe, ongoing group exercise after formal rehabilitation ends.

“Being part of Lungs in Action has helped me stay active and feel less isolated. It’s made a real difference to my quality of life,” one participant said.

Culturally safe care for First Nations communities is a priority. By working closely with Aboriginal Medical Services (AMS), LWYW delivers outreach clinics, rehabilitation and education tailored to local needs. A standout innovation is the Murundhu, I Live I Breathe program, developed with Griffith AMS and expanded to Wagga Wagga with Riverina Medical and Dental Aboriginal Corporation (RivMed).

“Murundhu is a pulmonary rehabilitation program created specifically for First Nations participants, using yarning circles to boost engagement and literacy,” Ms Holtby said.

“Participants are linked with ongoing community exercise options such as Aunty Jean’s, promoting lasting health and connection.”

In general practice, LWYW has also introduced software prompts for early diagnosis. Following a previous prompt in Medical Director to help GPs identify people who may

have a missed diagnosis of COPD, a similar prompt for suspected heart failure was rolled out from November 2024 to March 2025.

“The prompt helped GPs pick up people who might otherwise have fallen through the cracks and helps ensure timely diagnosis and care,” Ms Holtby said.

Beyond clinical care, LWYW is about building a cohesive, cross-organisational team culture. Staff from MLHD and MPHN share workspaces to build joint leadership. This integrated approach has improved implementation and partnerships.

“This work is important because it is about streamlined access to quality care regardless of how you enter the system,” Ms Holtby said.

WINTER STRATEGY PROGRAM

18

general practices implemented the Heart Plan in a Box toolkit for heart failure management

113 staff attended training, including spirometry and ECG workshops

LUNGS IN ACTION

9 providers trained 6 programs delivered

13

education sessions delivered to general practice teams

51

clinicians trained in spirometry across five locations in May 2025

87 participants

“By working together, MPHN and MLHD can make a real difference to a person’s continuity of care and enable them to stay well in their home and community.”

2025 marks LWYW’s third year of operations. To evaluate Collaborative Commissioning’s impact, the George Institute for Global Health is leading an independent study in partnership with NSW Health.

“The goal is to understand how collaborative, locally designed care can deliver better outcomes and more sustainable health services for communities,” Ms Holtby said.

Findings from Murrumbidgee and other regions will inform future care models statewide.

SUMMER STRATEGY –NURSE LED CLINICS

18 participating general practices with 20

nurses delivering care to 252 people across

106 clinics

OUTREACH HEART FAILURE DIAGNOSTIC CLINICS

137 people were seen across 16 clinics in Tumut, Holbrook, Lake Cargelligo, Harden, West Wyalong, Hay, Narrandera, Gundagai, Temora, Finley, and Henty

Living Well, Your Way’s Fiona McKern presenting a poster about the Outreach Heart Failure Diagnostic Clinic at the National Rural Health Conference, September 2024

Innovation in pAediAtriC care transforms young lives

MPHN is leading collaborative reform to improve early childhood health outcomes across the Murrumbidgee, ensuring children receive timely, coordinated care close to home.

Children in rural communities often experience poorer health outcomes due to a lack of access to appropriate screening, assessment and treatment services, but MPHN’s Enhancing Paediatrics in Primary Care (EPiPC) program was developed to help address these challenges.

Co-designed in 2019/20, Executive Integration and Partnerships, Narelle Mills said EPiPC has evolved and grown since the initial pilot program.

“Feedback from the EPiPC pilot showed an increase in confidence among general practitioners to complete screening and behavioural assessments, and when looking at pre and post event data, we can see confidence improving across the board, which is now leading to positive outcomes for children by improving continuity of care and reducing the risk of children falling through the gaps,” Ms Mills said.

“The program has also developed and provided standardised screening, assessment, and referral tools to support appropriate developmental screening to facilitate treatment at an earlier age including referral to multidisciplinary assessment.”

For the 24-25 financial year almost 22 clinics have been conducted, and 58 children supported through WARATAH For Kids.

Central to the program is Community Paediatrician Dr Lahiru Amarasena, who works to enhance capability and capacity of general practitioners and their teams to identify and appropriately manage the region’s most at-risk children between the ages of zero to seven who are experiencing developmental and behavioural issues.

“By increasing capabilities locally around children with behaviour and developmental issues, we hope to improve the diagnostic and management journeys for children and their families across the region,” Dr Amarasena said.

Delivered across three different streams of clinical support, enhancing GP skills, confidence and capabilities, and integrated paediatric clinics, general practitioners in nine locations are provided with upskilling, assessment tools and consultation support to enable vulnerable children to receive care in their own communities. This often negates travelling time and costs to access private specialist paediatricians.

Program participant, Dr Rachel James from Deniliquin Clinic has found the clinical support key to managing her youngest people.

“Having someone like Dr Amarasena who is a trained community paediatrician, can really support you in those

Michelle Houghton-Taylor presenting at the EPiPC CPD event, November 2024

areas which you might not be hugely confident with. For example, I want the confidence to be able to support my people with up to date and relevant information and screening tools so I can ensure there is nothing else this child, living in Deniliquin, a rural town, is missing out on compared with a child who is living in a bigger resourced setting,” Dr James said.

“We know any interventions put in place in those early years have a huge impact on the child’s school and home life, and into adulthood. So, it’s one of the more important areas of general practice, but it can be challenging to navigate.”

While the program is certainly supporting the region’s local workforce, it’s the improved health outcomes that demonstrate the value of such an innovative program.

“Recently we learned about a three-year-old child with mild developmental difficulties and a five-year- old with sensory behaviours who were both able to access appropriate services such as allied health and child and family health nursing without requiring specialist paediatric care. This not only streamlined referrals but also helped to ease the burden on local paediatric services” Ms Mills said.

Building on the work already underway in the Murrumbidgee, MPHN has been instrumental in leading

3 program streams

clinical support

GP capability building integrated paediatric clinics

0–7 years

age group targeted for early intervention

9

general practice locations including Wagga Wagga, Deniliquin, Hay, Lockhart, Boorowa, Tumut, Holbrook, Gundagai, and Leeton

the establishment of the Murrumbidgee Paediatric Collective, a cross-sector partnership under the Murrumbidgee Health and Knowledge Precinct. The Collective brings together health, education, Aboriginal health and community organisations to create a unified system of care for children aged up to nine years.

“It’s a bold step forward in how we think about child development through aligning services, sharing knowledge and designing care pathways reflective of the real needs of families in our region,” Ms Mills said.

“Children and families come first — and that means meeting them where they are, with care that’s coordinated, inclusive and informed by local experience.”

By investing in early childhood supports and building a more connected system of care, MPHN is shaping a healthier future for the Murrumbidgee region’s children.

Enhancing Paediatrics in Primary Care

Is your child under 7 years old?

Worried about their behaviour or development but not seeing any professionals?

Not sure where to start or who to talk to?

For more information, talk to your GP today!

“I want the confidence to be able to support my people with up to date and relevant information and screening tools so I can ensure there is nothing else this child, living in Deniliquin, a rural town, is missing out on compared with a child who is living in a bigger resourced setting.”

DR RACHEL JAMES

Murrumbidgee Primary Health Network and Murrumbidgee Local Health District.

Strengthening rural health through reSeArCH and data-driven innovation

From medication safety to chronic disease surveillance, MPHN’s research activities have focused on building partnerships, generating local insights, and translating evidence into action.

Over the past financial year, MPHN has deepened its commitment to research and evaluation, a key focus of its Strategic Plan. Through collaborative partnerships and data-driven inquiry, the organisation has advanced several initiatives aimed at improving health outcomes across the Murrumbidgee region.

Among the most significant initiatives was the ASPIRE trial, A Systems-Approach to Enhancing CommunityBased Medication Review, which brought together MPHN, Murrumbidgee Local Health District (MLHD), community pharmacists, and the University of Sydney.

MPHN’s Acting Chief Data Officer Dr Ryan Du Toit (PhD) said the ASPIRE trial exemplified how collaborative research can drive practical solutions in rural health.

“Over the course of the trial, ASPIRE enrolled 280 participants, achieved 17 credentialed pharmacists and hosted two Continuing Professional Development (CPD) events. Those trial participants and credentialed pharmacists explored whether a coordinated postdischarge medication review could reduce unplanned hospital readmissions,” Dr Du Toit said.

“The model included hospital-based pharmacists identifying people at risk, followed by timely reviews coordinated by MPHN’s Medication Safety Pharmacist which also allowed for communication pathways between hospital and primary care to be strengthened.

“We’re looking forward to the results from the trial which are currently being analysed by the University of Sydney with outcomes expected in mid-2026.”

MPHN’s ongoing involvement in the Strengthening Care for Rural Children (SC4RC) program also reflects its commitment to improving care through research.

SC4RC is a GP-paediatrician integrated model of care and evaluation conducted as a collaboration between MPHN, the University of New South Wales (UNSW), the

University of Melbourne, MLHD, Western Victoria PHN, and the Barwon Health and Ballarat Health Services.

Two members of the UNSW research team are co-located with MPHN and Project Manager Susan Bullock said SC4RC aims to strengthen paediatric care in primary settings by connecting local GPs with paediatric consultants.

“The SC4RC model of care is operating in 10 general practices and providing paediatric support to 56 local GPs. These GPs have co-consulted both in-person and virtually with paediatricians to provide care for children in more than 300 individual appointments,” Ms Bullock said.

“The project is assessing the model’s impact on GP referrals to public and private paediatric services, the quality of GP-led care, and confidence among GPs and families in primary-level paediatric care.

“We’re interviewing GPs, practice staff, paediatricians and families to understand their views and identify factors that will help refine and sustain the model across diverse settings.”

In another demonstration of data-driven innovation, MPHN presented a proof-of-concept analysis at the NSW Ministry of Health Lumos Community of Practice, which compared chronic disease prevalence estimates from the Lumos general practice data with those from the ABS 2021 Census.

Dr Ryan Du Toit said chronic diseases, including coronary heart disease, dementia/Alzheimer’s, cerebrovascular disease, and Chronic Obstructive Pulmonary Disease (COPD), are the primary causes of morbidity and mortality among Australian adults.

“While regular chronic disease monitoring is essential for describing patterns and trends, and identifying at-risk population sub-groups, limited chronic disease surveillance systems are available in Australia, particularly in our region,” Dr Du Toit said.

“Since many adults regularly visit their GP, data from these interactions may help provide valuable information on localised chronic disease prevalence, and this was the premise of our research – to understand if GP level data could provide improved insights and health planning.

“While the findings offer promising insights into the value of GP-derived data and comparisons showed statistically significant differences, the effect sizes were generally small. To strengthen the validation of these preliminary findings, further analysis of the available data will be explored.”

Dr Ryan Du Toit said together, all of these research partnerships and activities demonstrate MPHN’s commitment to a strategic approach to research.

ASPIRE Griffith CPD event, March 2025

ASPIRE TRIAL

280 participants

10 general practices

17 credentialed pharmacists

SC4RC

56 general practitioners

2 CPD events

300 appointments

“By embedding research into local systems, we’re not just generating evidence, we’re building capacity and improving health outcomes for people living in the region.”

DR RYAN DU TOIT (PHD), MPHN

MPHN RESEARCH ON THE NATIONAL STAGE

Sharing MPHN’s research on a national stage ensures the unique challenges and insights from our rural communities inform broader health policy, spark collaboration, and drive innovation in service delivery across Australia.

In September 2024 at the 17th National Rural Health Conference held in Perth, MPHN presented new findings on homelessness in the Murrumbidgee region. Using ABS Census data, the study revealed a significant rise in homelessness between 2016 and 2021, with the highest increases in Wagga Wagga and the region’s western sector. The analysis highlighted growing challenges for people in supported accommodation and severely crowded dwellings.

During the same event, MPHN also shared insights from its “Conversations on the Couch” initiative via a poster presentation. This qualitative study captured community voices on primary healthcare experiences, identifying key themes around access, affordability, and mental health service gaps. Together, these presentations demonstrate MPHN’s commitment to evidence-informed planning and improving health outcomes in rural communities.

Strategic enAblerS

KEY ACHIEVEMENTS:

17 new Clinical Council members recruited to improve clinical voice as part of MPHN’s Governance ...page 60

Establishment of MPHN’s new culture and engagement program – SPARC (Skills, People, Agility, Relationships, Culture) ...page 62

More than 80 percent of MPHN’s Reconciliation Action Plan deliverables achieved ...page 62

Joint regional planning continued between MPHN and Murrumbidgee Local Health District ...page 64

Continued policy advocacy on behalf of the region ...page 64

Publication of Disaster Management Framework ...page 64

Digital health and Artificial Intelligence focus of joint Board, Community Advisory Committee and Clinical Council annual meeting ...page 60

Re-accreditation of ISO9001 Standard achieved with no-non conformances ...page 62

LEADING WITH PURPOSE:

Strengthening leadership and governance for greater impAC t

With a renewed focus on collaboration and community voice, MPHN is embedding effective leadership and Governance into every layer of its work.

At MPHN, effective leadership and Governance are the foundation of how the organisation operates. From the Board and its sub-committees to the Clinical Councils and Community Advisory Committee (CAC), MPHN’s Governance structures are designed to ensure decisions are informed, inclusive, and aligned with community needs.

MPHN CEO Stewart Gordon said MPHN’s Governance framework which includes expert clinical and community advice, aims to support informed, values-aligned decisionmaking.

“Our Governance structures ensure the PHN is accountable, transparent, effective, and well grounded with our community,” Mr Gordon said.

This approach was reinforced during the Board and Executive Leadership Team’s Strategy and Risk Workshop, which included a mid-year to review of MPHN’s Strategic Plan.

“The headline from the day is that our Strategic Plan is fit for purpose and we’re pleased with the progress we’ve made, but we’re also focused about the work ahead,” Mr Gordon said

“As we move into the second half of the plan’s implementation, our focus will sharpen on how we measure impact and adapt to emerging challenges.”

Board, Clinical Councils, and CAC meeting, March 2025

The commitment to inclusive and collaborative Governance was further demonstrated at MPHN’s annual joint meeting of the Board, Clinical Councils, and CAC in March 2025. Held in Wagga Wagga, the event brought together more than 40 participants for a full-day program focused on the role of digital health and artificial intelligence in transforming primary care.

MPHN’s firsthealth Board Director Dr Alam Yoosuff, who delivered the Board’s welcome address, said the meeting was a valuable opportunity to strengthen relationships and reflect on shared goals.

“When clinicians, community and health organisations work together, we can affect meaningful change and improve health outcomes for people,” Dr Yoosuff said.

“The advice provided by our Clinical Councils and CAC is considered and reflected upon in our Board meetings. These connections are essential to our success.”

The day featured presentations from national digital health experts Duane Attree and Tim Blake, who explored the pace of technological change and the opportunities for AI to support more connected, person-centred care. Participants engaged in group activities to explore how digital tools could be applied locally to address regional health challenges.

Mr Gordon said the joint meeting was a powerful demonstration of MPHN’s commitment to transparency and co-design.

Clinical Governance Committee

Finance, Risk, Audit and Cybersecurity Committee

PHN BOARD

Clinical Councils

Community Advisory Committee

CHIEF EXECUTIVE OFFICER

“Bringing together our Governance and advisory bodies in one room was powerful. The conversations were rich, and the outcomes will shape how we work together moving forward,” Mr Gordon said.

Throughout the year, MPHN’s Clinical Councils explored a wide range of health priorities including chronic disease management, cancer screening, and digital health innovation. They also provided strategic input into MPHN’s Health Needs Assessment (HNA), and the development of tools such as the First Nations General Practice Toolkit and Allied Health Strategy.

The CAC focused on community-driven priorities such as mental health access, palliative care, emergency management, and immunisation. Their guidance helped shape MPHN’s regional planning, including the Community Engagement Plan and the HNA for 2025–2028.

MPHN’s Senior Lead, Engagement and Design – GP Initiatives, Andrew Heap, said the Clinical Councils and CAC are integral to the organisation’s Governance model.

“Our Clinical Councils and CAC are not just advisory— they’re active partners in shaping our direction,” Mr Heap said.

“This year, we’ve seen a stronger focus on local issues and HNA priority areas, and the insights from members are helping us align our activities with local needs.”

The 2025 Clinical Council recruitment campaign aimed to attract diversity in health disciplines from across the region including general practice, allied health, pharmacy, aged care, and mental health. Seventeen new members were inducted to their respective Clinical Councils in mid-2025.

As MPHN continues to deliver on its Strategic Plan, the Effective Leadership and Governance enabler remains central. With strong advisory structures and a culture of collaboration, MPHN is well-positioned to navigate system complexities and drive meaningful change.

Board Governance Committee Innovation Committee

CLINICAL COUNCIL AND CAC MEMBERS 2024–2025

BORDER CLINICAL COUNCIL

Dr Marion Magee (Chair), Dr Rachel James, Laura Ross, Lourene Liebenberg, Josh Jones, Jeremy Carr, Simon Lloyd, Julianne Whyte, Catherine Ryan (Board representative)

RIVERINA CLINICAL COUNCIL

Dr Joe Murphy (Chair), Peta Cullis, , Luke Peacock, Evan Feather, Lee Francis, Dr Jacques Scholtz (Board representative)

WAGGA WAGGA CLINICAL COUNCIL

Dr Rachael Fikkers (Chair), Carin Lewis, Tom Shumack, Kim Aylward, Dr Ayman Shenouda, Dr Trudi Beck, Dr Jodi Culbert (Board representative)

WESTERN CLINICAL COUNCIL

Dr Bhupinder Kumar (Chair), Karen Ingram, Leanne Baulch, Dr Khaled Bardawil, Dr Muhammad Shahzad Arshed, Dr Shahid Abbas, Dr Muhammad Islam, Emma Kelly, Sean Dodd, Dr Alam Yoosuff (Board representative)

COMMUNITY ADVISORY COMMITTEE:

Rory McKenzie (Chair), Cheney Dewar, Jenny Atkinson, John Harper, George John, Olivia Jones, Marilyn Wales, John Moi, Dolf Murwood, Lee Ncube, Caitlin Reid, Richard Salcole, Kathleen Stewart, Matthew Clancy, Jean Van Asperen, Stan Warren, Jody Lindbeck (MLHD representative), Tegan Reid (MLHD representative), Peta Larsen (Board representative)

Building a thriving Culture

Its people are at the heart of everything MPHN does. Over the past year, MPHN has taken significant steps to strengthen our workplace culture, support our staff, and create an environment where collaboration, innovation, and wellbeing can flourish.

Twice a year, the MPHN team comes together for its Big Day In, a dedicated day designed to listen, connect, and co-create the future of MPHN. In April 2025, staff from across the region came together in Wagga Wagga to explore our desired future culture, identify ways to work with greater adaptability and innovation, and commit to practical steps for improvement.

MPHN CEO Stewart Gordon said the event has evolved into a powerful enabler of cultural change.

“We have strategically shifted the purpose of our Big Day In to align with our culture change program,” Mr Gordon said.

“It’s no longer just about bringing people together; it’s about harnessing collective insights and energy to shape a stronger, more connected, and empowered culture at MPHN.”

Feedback from The Big Day In and the 2025 staff survey revealed a strong desire for clearer communication, greater collaboration, and stronger support for innovation and thought diversity. In response, we launched the SPARC program (Skills, People, Agility, Relationships, and Culture), designed to foster open conversations about leadership, strengthen the way we work together, and build a better workplace culture.

These initiatives directly shaped our Culture Action Plan, which supports a more agile, inclusive, and innovative MPHN. Participation in our March 2025 staff survey reached 81 percent. Highlights include 84.9 percent of staff reporting they understand how their work contributes to organisational success, 81.1 percent agreeing that managers communicate effectively, and 75.8 percent feeling clear about expectations in their role.

MPHN has also made meaningful progress against our Reconciliation Action Plan (RAP), guided by our vision of an ever-learning culture that acknowledges, listens to, celebrates, and embraces Aboriginal and Torres Strait Islander communities across the Murrumbidgee. Our RAP commits us to ensuring that all decisions about the health and wellbeing of Aboriginal and Torres Strait Islander peoples are made with their knowledge, involvement, and collaboration.

MPHN has now completed more than 80 percent of its RAP deliverables and finalised a staff engagement strategy to strengthen involvement across the organisation. First Nations resources are available within departments, and cultural education programs continue to deepen understanding and inclusivity across the organisation. These actions mark important steps towards building authentic relationships, acknowledging past injustices, and contributing to a reconciled and united Australia.

Big Day In, April 2025

This year, MPHN celebrated Naomi Richards’ 10year anniversary with MPHN. Reflecting on her decade with the organisation, Naomi shared that her favourite thing about working at MPHN are the people she gets to see every day. “I love coming to work and seeing friendly faces. Being part of an organisation that helps people is rewarding. Having had my own health issues, I can see that what we do makes a real difference.”

Alongside our cultural initiatives, we introduced Perform+, a structured HR system that provides every staff member with a clear work plan, regular performance conversations, and opportunities for growth and development. This ensures staff know what is expected of them, receive timely feedback, and have access to learning opportunities for career progression. To complement this, our People and Culture team continues to offer wellbeing activities, including lunch and learn sessions on positive psychology, mindfulness, and psychosocial awareness, helping staff thrive both professionally and personally.

This year has been one of listening, learning, and laying strong foundations. Through the Big Day In, SPARC, Perform+, RAP commitments, and wellbeing initiatives, we are building a workplace where every staff member feels valued, connected, and empowered to succeed.

81%

staff participation in the March 2025 staff survey

84.9%

understand how their work contributes to organisational success

81.1% agree managers communicate effectively

75.8% are clear on their role and expectations

RECONCILIATION ACTION PLAN

More than 80% of RAP deliverables completed

“I love coming to work and seeing friendly faces. Being part of an organisation that helps people is rewarding. Having had my own health issues, I can see that what we do makes a real difference.” 10 years of service

Engaging and partnering to enable system tr AnSfOrmAtiOn

At MPHN, our people are at the heart of everything we do. Over the past year, we have taken significant steps to strengthen our workplace culture, support our staff, and create an environment where collaboration, innovation, and wellbeing can flourish.

Across the Murrumbidgee, health system transformation is being driven by a shared commitment to collaboration, engagement and partnerships. Initiatives like Living Well, Your Way (LWYW), Collaborative Care, and joint regional planning are central to progressing the region’s shared vision of one health system.

Much of this work stems from the partnership between MPHN and Murrumbidgee Local Health District (MLHD), with both organisations co-designing and delivering initiatives that respond to local needs. MPHN’s Executive Integration and Partnerships Narelle Mills said the partnership is enabling a new way of working.

“We’re seeing the power of collaboration in action. By aligning our efforts and listening to our communities, we’re building a more connected and responsive health system; one that puts people at the centre and supports them across their entire care journey.”

Ms Mills said the Patient Centred Co-commissioning Group (PCCG), co-chaired by the Chief Executives of MPHN and MLHD, is a key enabler of system-wide change.

“LWYW is one of our flagship programs. It supports people with Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF) by integrating acute, primary and community care, public and private providers, and supporting people from early diagnosis to rehabilitation.”

Another partnership program is Leeton Collaborative Care, led by Rural Doctors Network and Leeton Shire Council.

“Leeton Collaborative Care is a strong example of place-based planning in action. It’s about listening to the community and designing services that reflect their needs. By working with local partners, we hope to improve access and deliver a more integrated health service experience,” Ms Mills said.

MPHN continues to lead joint regional planning, including the updated Joint Regional Mental Health, Suicide Prevention, and Alcohol and Other Drugs Plan (2025–2030). MPHN’s Senior Manager Priority Populations Anita McRae said the plan builds on the success of the inaugural 2021 version.

“This plan reflects the voices and experiences of our communities. It’s shaped by local insights and built through genuine collaboration—especially with people who have lived and living experience. Our goal is to create meaningful change by improving access and outcomes for people who often face the greatest barriers to care.”

The NSW Mental Health and Suicide Prevention Bilateral Agreement has helped streamline funding and resources, improving coordination across state and federal initiatives.

System transformation is also being led through the Murrumbidgee Health and Knowledge Precinct (MHKP), with MPHN supporting the development of a Regional Planning Framework.

“Co-designed with stakeholders, the framework provides a structured approach to joint planning, aligning with state and national strategies,” Ms Mills said.

“It promotes shared health intelligence, integrated service models, joint investment and Governance, and continuous improvement through data-driven evaluation. It’s already being applied to initiatives like the Paediatric Roundtable, which is focused on improving care pathways for children with developmental vulnerabilities.”

Government engagement has played a key role in showcasing the region’s innovation. MPHN hosted Chief Allied Health Officer Anita Hobson-Powell, who toured Glenrock Medical Practice, Active Health Riverina, and Marathon Health to learn about multidisciplinary team models.

MPHN CEO Stewart Gordon said the visit was a valuable opportunity to highlight the region’s leadership in allied health integration.

“We were proud to welcome Anita Hobson-Powell and to showcase how allied health are being engaged as part of multidisciplinary teams. These models—whether colocated, group-based, or contracted—demonstrate how regional providers are innovating to meet community needs and deliver truly team-based care.”

MPHN also welcomed federal representatives including Assistant Minister for Mental Health The Honourable Emma McBride MP, Senator Deborah O’Neill, and Federal Member for Riverina The Honourable Michael McCormack MP, highlighting MPHN-funded services such as Medicare Mental Health Centres in Wagga Wagga and Young, and headspace centres in Wagga Wagga and Griffith.

At the state level, MPHN participated in a Seniors Forum hosted by State Member for Wagga Wagga Dr Joe McGirr.

“We’re proud to showcase the innovation happening in our region. These visits allow us to demonstrate the value of local partnerships and advocate for the resources and

policy settings needed to sustain and scale what works,” Mr Gordon said.

Through authentic engagement, strategic partnerships, and shared leadership, MPHN is enabling a more connected, responsive, and person-centred health system reflective of the needs and aspirations of the Murrumbidgee community.

OUR ENGAGEMENT PARTNERS

Patient Centred Co-commissioning Group with MLHD, Murrumbidgee Aboriginal Health Consortium, Murrumbidgee Mental Health Drug and Alcohol Alliance, Murrumbidgee Suicide Prevention and Aftercare Collaborative, Murrumbidgee Local Response Group, Murrumbidgee Aged Care Consortium, Murrumbidgee Health and Knowledge Precinct, MPHN’s Clinical Councils and Community Advisory Committee, MPHN’s GP Advisory Group, Murrumbidgee Allied Health Advisory Committee, 31 Local Health Advisory Committees across the region.

CELEBRATING 10 YEARS!

In 2025 the Murrumbidgee Mental Health Drug and Alcohol Alliance marked its 10th anniversary. Since its inception, the Alliance has brought together mental health, suicide prevention and drug and alcohol service providers, community organisations, government partners and people with lived and living experience to improve outcomes for people experiencing mental health challenges, suicidality, and Alcohol and Other Drug (AOD) challenges. MPHN is a proud founding partner and active member, supporting initiatives like MapMyRecovery and the Lifespan Suicide Prevention Pilot. The Alliance continues to evolve, driven by lived and living experience, local knowledge and a shared commitment to building a more connected and responsive system.

Chief Allied Health Officer, Anita Hobson-Powell, visiting Glenrock Country Practice, July 2025

Responding to the region’s needs with Agility and excellence

MPHN’s strong internal systems and processes enable rapid adaptation to health reforms and evolving regional needs helping to consistently deliver excellence across programs.

Agility and operational excellence are essential organisational capabilities and MPHN continues to demonstrate its ability to respond swiftly and effectively to changing health needs, policy reforms, and environmental challenges, underpinned by robust systems, collaborative partnerships, and a commitment to continuous improvement.

This year, MPHN has contributed to several national and state-level inquiries and policy submissions.

MPHN’s CEO, Stewart Gordon, said the organisation’s work is grounded in community insights and clinical expertise, ensuring policy reform is informed by realworld experience.

“As a PHN we hear and understand the lived experiences of our communities and the insights of our clinical leaders, which allows us to actively contribute to policy conversations that shape a more equitable and responsive health system,” Mr Gordon said.

“We also reviewed the Royal Commission into Defence and Veteran Suicide Final Report published in September 2024 to identify opportunities MPHN could support veterans and their healthcare providers in the region. While funding isn’t specifically available, looking for way to provide support through existing activities, and learning more about the issues, MPHN is better positioned to advocate for supports when opportunities arise.”

MPHN also appeared before the NSW Select Committees on Remote, Rural and Regional Health, and Modern Slavery, reinforcing MPHN’s role as a trusted voice in rural health reform.

MPHN’s Senior Manager Priority Populations Anita McRae, who appeared at the Modern Slavery hearing in Griffith with Wagga Wagga GP and Clinical Council member Dr Trudi Beck, said the hearing provided an opportunity to highlight the health access challenges faced by migrant workers, particularly in relation to sexual health, reproductive health, pregnancy care and terminations.

“MPHN acknowledges the issues surrounding migrant health are complex and multi-layered and will require a human-centred systems change to ensure adequate health and wellbeing support is available for migrant workers,” Ms McRae said.

Operational excellence has been equally evident in MPHN’s internal systems and structures such as the use of online platforms to streamline workflow and improve efficiencies and reporting, and adapting to changes in the digital space.

MPHN’s Executive Commissioning and Operations, Julie Redway said these systems, processes and changes are enablers of organisational agility and excellence.

“Our internal platforms and policies provide the backbone of our ability to adapt and excel, which gives us the flexibility to respond quickly, and the structure to deliver consistently,” Ms Redway said.

“This year has seen us publish the Disaster Management Framework in December 2024 to support regional preparedness.

“Developed in collaboration with local and state partners, the framework outlines a comprehensive approach to disaster readiness, response, and recovery, tailored to the needs of primary care providers across the Murrumbidgee.”

MPHN also undertook a Commissioning Maturity Assessment, which provided an external review of its commissioning function and offered recommendations for further development. This work is now informing the creation of a new Commissioning Framework and Business Process, designed to embed commissioning as a shared responsibility across the organisation.

“Our commissioning maturity work is helping embed strategic commissioning across all teams, with the aim to build a commissioning model that’s both strategic and collaborative,” Ms Redway said.

“By integrating commissioning into all facets of our business operations, we’re ensuring our services are responsive, efficient, and aligned with community needs.”

MPHN’s commitment to quality underpins all business activities. This was reaffirmed in mid-2025 when the organisation successfully achieved ISO 9001 reaccreditation with no non-conformances.

“It’s a testament to the organisation’s robust systems and continuous improvement culture. The achievement reflects the dedication of our entire team and is a clear indicator of the high standards we uphold in everything we do,” Ms Redway said.

In preparation for ISO 27001 accreditation later in 2025, MPHN has also strengthened its Information and

Communication Technology (ICT) security systems, ensuring data protection and cyber resilience. The organisation has introduced an Artificial Intelligence (AI) Policy to guide ethical and responsible use of artificial intelligence and adopted Monday.com to streamline workflow and enhance cross-team collaboration.

From policy advocacy to disaster preparedness, and from commissioning reform to digital transformation, MPHN continues to lead with purpose and precision. Its ability to adapt and excel ensures that the health needs of the Murrumbidgee region are met with integrity, innovation, and care.

EXCELLENCE RECOGNISED ON THE NATIONAL STAGE

AWARDS AND PUBLIC ACKNOWLEDGEMENTS

MPHN’s Connect, Your Way mental health campaign continues to receive national acclaim:

• Purpose-Led Marketing Award – 2024 Australian Marketing Institute (AMI) Marketing Excellence Awards

• NSW Public Health Association Communication Award

• Mental Health Services Learning Network Award

• Highly Commended for Best Practitioner Paper – 2025 International Social Marketing Conference, Canberra

Palliative Care Project Officer Julie Mecham was selected to be on the Palliative Care NSW Management Committee.

CONFERENCE PRESENTATIONS

MPHN was invited to present at several major conferences, sharing insights from key initiatives:

National Rural Health Conference

• Connect, Your Way

• Reducing Mental Health Stigma through Storytelling

• Enhancing Paediatrics in Primary Care

• Rural Pharmacy Screening for Chronic Diseases

• Innovation in Heart Failure Diagnosis

• Rising Trends of Homelessness

• Listening to community voices: An exploration of primary healthcare experiences in the Murrumbidgee region

International Mental Health Conference

• Tell it Well series

• Connect, Your Way

APNA Festival of Nursing

• A model for collaborative commissioning and nurseled clinics – Living Well, Your Way

National Centre for Immunisation Research and Surveillance Conference

• MPHN presented its partnership with Foodbank and Murrumbidgee Local Health District (MLHD), showcasing innovative outreach strategies to improve immunisation access

International Social Marketing Conference

• Connect, Your Way

Kristy Hawkins and Cristy Houghton representing MPHN at the 2024 AMI Marketing Excellence Awards

Commissioned service providers and gr Ant reCipient S

A and N Medical Practice Pty Ltd (Boorowa Street Medical)

AbSec - NSW Child, Family and Community Peak Aboriginal Corporation

AG J & MG Japp (Japp’s Pharmacy)

Amponn Enterprises Pty Ltd (Coleambally Medical Centre)

Animoo Dispensary Pty Ltd & K.T Peacock & E.I Watt (The Bush Chemist Tumut)

Australian General Practitioners Pty Ltd (Kruger Medical Centre, Boorowa Hospital Medical Centre)

Australian Primary Health Care Nurses Association Ltd (APNA)

AW 1 SWP Pty Ltd (TerryWhite Chemmart Gundagai)

AW 2 SWP Pty Ltd (TerryWhite Chemmart Harden)

AW 3 SWP Pty Ltd (TerryWhite Chemmart Lockhart)

AW 4 SWP Pty Ltd (TerryWhite Chemmart West Wyalong)

Beacon Strategies Pty Ltd

BJ Crndusic & A Crighton (Jerilderie Pharmacy)

BJ Brndusic and C Fahmy (Terry White Chemmart Walla Walla)

BJ and SW Brndusic (Urana Chemmart Pharmacy)

Bonmoamapharm Pty Ltd & Moama RX Pty Limited (Moama Village Pharmacy)

Buddy Care Pty Ltd (Country Med Group)

C Davison & DP Spencer (HC Health Hub)

C Stewart Pharmacist Pty Ltd & Natnic Griffith Pty Ltd & Saavi Investments Pty Ltd & S.R Watt (The Bush Chemist Leeton)

C7EVEN Communications Pty Ltd

CA Flanigan & JB Hamit & ML McDonald (Moama Village Pharmacy)

Calvary Health Care Riverina Limited

Caremonitor Pty Ltd

Catholic Healthcare Limited

Centacare South West NSW Ltd

Charles Sturt University

Chiderek Medical Services Pty Ltd (Tumbarumba Medical Practice)

Colymedical Pty Ltd (Murrumbidgee Medical & Primary Care Centre)

ConsultX Pty Ltd

Cummeragunja Health and Development Aboriginal Corporation (Viney Morgan)

Directions Health Services Ltd

Dr Simon Wallace (Leeton Medical Centre)

Dr T Tran Pty Ltd (Connection Medical Centre Tumut)

Finley Regional Care Ltd

Mark Medical Services Pty Ltd (Fitzroy Medical Centre)

Furat Medical Services Pty Ltd (Rao Medical Centre)

Futian Pty Ltd (Soul Pattison Chemist Deniliquin)

Gallagher Family Company Pty Ltd as Trustee for Gallagher Family Trust (CBT Institute)

Gentle Pharmacy Pty Ltd (Junee Capital Chemist)

Geraldine Frances Duncan (Dr Duncan’s Room)

Gidget Foundation Australia

Giz A Break Limited

GP Super Clinic Pty Ltd (Quantum Medical Centre)

Grand Pacific Health Limited

Griffith Aboriginal Medical Service Aboriginal Corporation

GROW Australia

HammondCare

Har Nadar Pty Ltd (VeCare Health)

Healthy Communities Foundation Australia Limited

Hillstonmedicalcentre PTY LTD (Hillston Medical Centre)

HRDC Community Limited (Harden Grange)

Human Capital Alliance (International) Pty Ltd

J & C Carr Pty Ltd (Back on Track Physiotherapy)

J Cerra & Nia & Company Pty Ltd & PRS Pharma 1 Pty Ltd (Leeton Amcal Pharmacy)

Jenna Mooney (Nova Pelvic Health Pty Ltd)

Katherine Elizabeth Ludford

Kents Pharmacy Pty Ltd (Priceline Pharmacy Swan Hill)

KMG West Wyalong Pty Ltd (Kure Medical Centre)

Lachlan Lodge Incorporated

Leeton And District Local Aboriginal Land Council Inc

Lung Foundation Australia

Marathon Health Ltd

MedCirc Property Pty Ltd

Melissa Isobel Jane Merrin (Physiofamily)

Michael James Wainwright (In Motion Fitness)

Michael O’Reilly Pharmacy Pty Ltd

Mina Estafanos (Forest Hill Pharmacy)

Moama Health Group Pty Ltd

Moulamein Retirement Village Inc

Murrumbidgee Local Health District

Notitia Pty Ltd

NSW Service for the Treatment and Rehabilitation of Torture and Trauma Survivors (STARTTS)

Pasquale Zirilli (Amcal Max Griffith)

Phil Davies Pharmacy Pty Ltd

Pioneer St Pharmacy Pty Ltd (The Bush Chemist Batlow)

Pro Patria Centre Ltd

Qualicare Medical Services Pty Ltd (Roth’s Corner Medical Centre)

Queensland University of Technology

Ralifah Medical Centre Pty Ltd

Relationships Australia Canberra & Region Incorporated

Respect Group Limited (Respect Woodhaven)

Riverina Medical and Dental

Aboriginal Corporation

RJ Campbell Pty Ltd (Deniliquin Clinic)

Robertson Pharmacy (Young) Pty Ltd & Juju Man Pty Ltd (Blooms the Chemist Young)

Rotary Club of Deniliquin Incorporated

Royal Far West

Royal Freemasons’ Benevolent Institution (Leeton Masonic Village)

Sammit Solutions Pty Ltd (Evinco Health + Performance)

Sarkon Healthcare Pty Ltd (Sarkon Medical Centre)

SGFMC Pty Ltd ATF SGFMC Unit Trust (St George Family Medical Centre)

SCP Pty Ltd (Southcity Pharmacy)

Sunflower House Incorporated

Samual William Brndusic (TerryWhite Chemmart Narrandera)

Swan Hill District Health

Taryn Jena Field (Riverina Rehabilitation)

The Mary Potter Nursing Home and Ethel Forrest Day Care Centre

The Trustee for Aayush Health Care Trust (Urana Medical Centre)

The Trustee for the Agios Trust (Barooga St George Discount Pharmacy)

The Trustee for Anga Family Trust (Henty Medical Centre)

The Trustee for Berrigan Medical Practice Unit Trust (Berrigan Medical Centre)

The Trustee for Blamey Family Practice Unit Trust (Blamey Street Surgery)

The Trustee for Bond Medical Group Trust (Lockhart Medical Practice)

The Trustee for Cootamundra Medical Centre Unit Trust

The Trustee for Corowa Medical Centre Trust (Redgum Medical Group: Howlong and Corowa)

The Trustee for Cowra Pharma Trust & The Trustee for Jayson Atkins Investment Trust (Miegel’s Pharmacy Corowa)

The Trustee for CRMC Unit Trust (Coolamon Regional Medical Centre)

The Trustee for Dan Pettersson Medical Trust (Leeton Medical Practice)

The Trustee for Drive Thru Pharmacy Unit Trust (Drive Thru Pharmacy Griffith)

The Trustee for Guha Family Trust (Mulwala Medical Centre)

The Trustee for Gundagai Medical Centre Unit Trust

The Trustee for H&W Medical Trust (West Wyalong Medical Centre)

The Trustee for Hope Medical Services Unit Trust (Glenrock Country Practice: Glenfield, Lake Albert, The Rock)

The Trustee for JMC Services Trust (Junee Medical Centre)

The Trustee for Kookora Surgery Unit Trust

The Trustee for Leeton Medical Trust (Leeton Family Clinic)

The Trustee for Nova Health Co Unit Trust

The Trustee for Prime Care Doctors Unit Trust (Griffith Medical Centre, Hanwood Surgery)

The Trustee for Riverina Family Medicine Trust

The Trustee for St George Trust (Good Shepherd Family Medical Centre)

The Trustee for T M C Unit Trust No 2 (Temora Medical Complex)

The Trustee for the Ross Beaton Consulting Trust (Insight Consulting Australia)

The Trustee for the Vieira Family Trust (Trail Street Medical Centre)

The Trustee for the Young Medical Services Trust (Young District Medical Centre)

TMC (Wagga) Pty Ltd (TMC Medical Group)

Tocumwal Pty Limited (The Tocumwal Pharmacy)

Tooba Nasir (Kruger Medical Centre Harden)

The Trustee for the St. Stephanos Unit Trust (Trinity Medical Centre)

Tumut Family Medical Practice Pty Ltd

United Protestant Association of NSW Limited

Uniting (NSW, ACT)

Uzair Medical Services Pty Ltd (Hay Medical Centre)

Victor Tri Tai Vo (Ariah Park Pharmacy, Ardlethan Pharmacy)

Wagga Wagga Medical Centre Pty Ltd

Wagga Women’s Health Centre Inc

Wellways Australia Limited

Western Sydney Local Health District

mphn.org.au

Tel 02 6923 3100

Fax 02 6931 7822

1/185 Morgan Street

Wagga Wagga NSW 2650