2024 Annual Report

Building on

years ANNUAL REPORT

2023-24

firsthealth Limited trading as Murrumbidgee Primary Health Network

firsthealth Limited trading as Murrumbidgee Primary Health Network (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.

Contents Our region, our priorities 2 Chair report 4 CEO report 5 Our board 6 Our senior leadership team 7 Marking 30 years of primary healthcare 8 Implementing our strategic plan

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Snapshot of 2023-24 14 Being a voice for our region 16 Advocating for health in the Murrumbidgee 18 Innovating for impact 20 Driving local research opportunities 22 Understanding the region’s health needs 24 Out and about in the community 26 Making a difference 28 Child, maternal and women’s health 30 First Nations health 32 Caring for our seniors 34 Supporting mental health, and alcohol and other drugs needs 36 State recognition for suicide prevention work in the Murrumbidgee 38 Enhancing lives: our commitment to health and wellbeing 40 Care in the after hours period doesn’t always need to be an emergency 42 Supporting health professionals 44 Helping implement primary healthcare reform locally 46 Supporting general practice 47 Vaccinations and seasonal planning 48 HealthPathways: a key tool for improving patient care 50 Healthy digital connections 51 Inaugural forum for commissioned service providers 52 Fostering allies in health 53 Recognising excellence in primary healthcare 54 One health system 56 Living Well, Your Way 58 Improving access to diabetes care 60 Enhancing paediatric care for a brighter future 61 Medicare Mental Health Centres for Wagga Wagga and Young 62 System transformation and integration in the one precinct 63 Living our values 64 A great place to work 66 Treasurer’s report 68 Grant recipients 70 Commissioned service providers 70

Our region, our priorities population

125,500

252,358

males

(49.9%)

508

126,858

79.0 years

communities

females

life expectancy

126,124km

37.4%

0.1-16.6

21.9%

land area

2,387

(50.1%)

83.9 years

obese

life expectancy

smokers

51,269

over 65 years

34.9%

(21.6%)

14.1%

20.4%

obese

persons/km2 population density

total births

consume alcohol at risky levels

smokers

11.7%

psychological distress

Lachlan (part)

Carrathool

70.2% inactive

Bland

Griffith

Hay

Temora

Leeton Murrumbidgee Narrandera

Coolamon Junee

Edward River Murray River

Lockhart

Berrigan

Hilltops

Wagga Wagga

Federation

Cootamundra -Gundagai Regional

Snowy Valleys Greater Hume Shire

2

Western

Wagga Wagga

Border

Riverina 2023-24 Annual Report

43.0%

Aboriginal and

consume alcohol at risky levels

higher prevalence

(5.9%)

29.6%

of cardiovascular disease, diabetes, kidney disease and cancer

15,408

Torres Strait Islander

smoke

74.1 years

45.5%

life expectancy

obese

2,033

over 55 years

of mental health conditions

(13.2%)

WIRADJURI

YITHA YITHA

NARI NARI WEMBA WEMBA

higher prevalence

NGUNNAWAL PEREPA PEREPA

YORTA YORTA

NGARIGO BANGERANG

*Artistic impression only

2023-24 Annual Report

3

Chair report For me reflecting on our achievements and challenges provides an opportunity to build on our experience.

As we seek inputs from our stakeholders to continue supporting the region’s health workforce and improve health and wellbeing for people living across the Murrumbidgee.

For MPHN and the firsthealth Limited Board, the 2023-

policy challenges and showcased several local initiatives

24 financial year has seen significant leadership changes,

aimed at improving health efficiencies and outcomes.

organisational milestones and the navigation of national and state health reforms, inquires and policies to ensure our broad stakeholders understand the impact locally, and to advocate on their behalf.

This year also saw the resignation of Melissa Neal from the position of CEO after seven years in the role in late 2023. During her tenure Melissa led the MPHN through significant periods of growth, and her advocacy for and

Throughout this period, we marked providing primary

commitment to regional and rural health have improved

healthcare support to the region for 30 years, culminating

health outcomes for Murrumbidgee communities.

in a celebration event in May. For me reflecting on our achievements and challenges provides an opportunity to build on our experience. As we seek inputs from our stakeholders to continue supporting the region’s health workforce and improve health and wellbeing for people living across the Murrumbidgee.

Our work with the Murrumbidgee Local Health District through our joint Collaborative Agreement to build a local health system through a one-door approach, is one of these opportunities. I’m pleased we have been able to progress a range of activities under this agreement with the aim to reduce fragmentation and improve care coordination.

I would also like to acknowledge and thank Narelle Mills for her leadership as Interim CEO for period of six months until our current CEO, Stewart Gordon, was recruited. In this time Narelle actively progressed the work of the business and continued to foster stakeholder relationships and employee engagement.

Finally, I would like to sincerely thank MPHN’s employees for their passion, commitment, and flexibility in delivering your many projects. Your achievements, as outlined in this Annual Report directly contributes to improving health outcomes for our communities. I’m looking forward to seeing what is achieved next year when we will mark 10 years of being a primary health network.

Central to system improvements is being involved in health reform implementation and advocacy and contributing to policy reviews and inquiries when necessary. It was pleasing to host Assistant Minister for Rural and Regional Health, The Honourable Emma McBride MP on two occasions, and we discussed health

Dr Jodi Culbert

workforce and local implementation of health reform 4

2023-24 Annual Report

CEO report It is clear MPHN has a well-established culture of collaboration, partnerships, advocacy and innovation, and to me these are our strengths.

What a pleasure it is to provide this report as MPHN’s

Melissa Neal, and together, both Narelle and Melissa

newest CEO. It truly is a privilege and honour to lead such

delivered exceptional leadership which is a testament to

a reputable PHN like Murrumbidgee.

the achievements documented in this 2023-2024 Annual

While this Annual Report documents MPHN’s

Report.

achievements prior to my commencement, it is clear

Thanks too, to all of MPHN’s employees, especially those

MPHN has a well-established culture of collaboration,

who undertook secondments during the CEO transition

partnerships, advocacy and innovation, and to me these

period. Each employee enables the implementation

are our strengths.

of our Strategic Plan through supporting our primary

For me, the ‘innovation moments’ captured throughout this report demonstrate the power of finding locally-led solutions to local challenges. As someone who is country born and bred, I know country people have a can-do attitude and always look for innovative ways to address problems, often using existing resources.

Looking ahead, I am excited to see expansion and growth in our innovation, advocacy and research work, and the continuation of our collaborative partnerships to integrate our local health systems to improve efficiencies, deliver better value of money, and most importantly, healthier

healthcare workforce, funding services to address the region’s health needs, and working with partners to integrate and transform the local health system. Your efforts and achievements are commendable and directly support improved outcomes.

As I continue to deepen my understanding about the organisation, our community and the region’s health needs, I am looking forward to continuing to build on the 30-year legacy of the organisation and progress our vision of Well People, Resilient Communities across the Murrumbidgee.

people and communities. All of this will be achieved through the implementation of our Strategic Plan, and in alignment with national and state health reforms.

I would like to take this opportunity to sincerely thank Narelle for all the work she has done in the Acting CEO

Stewart Gordon

role for most of 2024, and for assisting with my transition to CEO. I also acknowledge the work of previous CEO

2023-24 Annual Report

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Our board 2023-24 financial year Peta Larsen Dr Jacques Scholtz 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.

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.

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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 MLHD 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.

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 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.

Peta, an Accredited Practising Dietitian, and has held senior health management positions across acute, primary health and community settings 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.

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.

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.

2023-24 Annual Report

Our senior leadership team 2023-24 financial year

Narelle Mills

Anita McRae

Interim Chief Executive Officer

Senior Manager, Priority Populations

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.

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.

2023-24 Annual Report

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.

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.

Julie Redway

Andrew Heap

Executive Commissioning and Operations

Senior Manager, Primary Care Engagement

Julie has a passion for delivering outcomes for health service providers and consumers. Having started her career in medical science, Julie transitioned into the primary care environment in 1993. 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).

Andrew has spent the last 10 years in the field of primary care engagement and has a particular interest in current and emerging digital health solutions and continual quality improvement.

Andrew has experience in acute and primary health sectors in metropolitan and rural settings and holds qualifications in medical science (Pathology) and music.

Melissa Neal Chief Executive Officer Appointed as CEO in 2018, Melissa is committed to developing local partnerships and working with organisations to improve outcomes for people and communities across the Murrumbidgee.

During her 20-year career in the primary health and community services sector, Melissa has gained experience in governance, leadership, strategic management, human resources and industrial relations.

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. While mental health and suicide prevention are areas of interest, Janelle also has an affinity for data and how it relates to decision making.

Toni Preuss Senior Manager, Integration Toni has been with MPHN since 2006, bringing her expertise from roles in workforce, commissioning, and integration programs.

Toni values her long-term contribution to MPHN’s growth and is passionate about collaborating with healthcare providers to enhance outcomes.

Toni holds a Bachelor of Business Studies and a Masters of Business Administration.

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Marking 30 years of primary healthcare In 2023-24, MPHN proudly celebrated its 30th anniversary, marking three decades of dedicated service to primary care providers and the community.

The milestone event to celebrate the organisation’s

“However, regardless of the remit determined by the

30 years of operation was held on Friday 17 May 2024

government of the day, there has been one constant –

in Wagga Wagga, and brought together stakeholders,

an organisation dedicated to improving the health and

current and past employees, board members, and friends

wellbeing of our communities and the primary healthcare

for an evening of reflection and celebration.

workforce who care for our residents.”

In her welcome address, firsthealth Board Chair Dr Jodi

The 30 year timeline displayed on the night showcased

Culbert reflected on the challenges and triumphs faced by

the organisation’s history and achievements during this

MPHN, and the resilience and commitment of the team

time as revealed through annual reports, media clippings,

to overcome obstacles in the pursuit of better health

and anecdotal feedback from past and current employees

outcomes.

and stakeholders.

“Since the organisation’s humble beginnings in the mid-

“While the archives uncovered various workplace stories

1990s supporting general practices in Wagga Wagga and

and legends, they also revealed that many of those early

surrounds and a handful of staff, it now support various

day challenges remain today. The final report for the first

primary healthcare providers and community across a

year of operations states the health workforce in the

much larger geographic area with around 70 employees.

region as a ‘major problem’. Thirty years on we are still

During its time as Murrumbidgee Medicare Local the

grappling with this very same challenge. Just as we did

organisation was different again – delivering primary

in the 90s, we continue to look for innovative options

healthcare services and a staff of in excess of 130,” Dr

to address health workforce shortages,” Dr Culbert

Culbert said.

continued.

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2023-24 Annual Report

“In that same report, we also find the first organisation

“For those of you who were privileged to be involved with

workplan. On it is listed a goal to connect 95 percent

the organisation during Nancye’s tenure, you will know

of general practices to a fax machine, as well as a few

how much grit and determination she had to keep our

projects to undertake including ones for diabetes, the

organisation alive before we became a Primary Health

development of a health services directory, and a best

Network,” Dr Culbert said.

practice project with St Vincent’s hospital. It’s interesting to learn a localised health services directory was just as important all those years ago as it is today. We are still looking at ways to manage and reduce diabetes and

“In fact, organisation legend has it that Nancye is credited

working with St Vincent’s hospital on this.

with ensuring MPHN became

“While many of the projects and challenges from those

the nation’s 31st PHN, when

early days are similar today, the strong foundations and partnerships created throughout the past 30 years positions us well to continue to innovate, inspire and transform the local health system.”

The celebration event was emceed by the Acting CEO at

only 30 were originally planned.”

Dr Jodi Culbert

the time, Narelle Mills who has worked for MPHN in its

Dr Culbert, Ms Mills and Ms Piercey were also part of a

various iterations for 18 years.

panel discussion on the night, along with Peter Keith, a

“I’ve had many varied roles within the organisation, and during this time, I’ve seen a lot of things change, and yet some things still remain the same, but the organisation and importantly the people who have worked or still

founding GP and former Board Director. Together they shared their experiences and insights and reminisced about the early days of the organisation, highlighting the camaraderie and dedication that fuelled its growth.

work here, along with our many partners are genuinely

In celebrating 30 years of primary healthcare, the

passionate about making a difference, and that’s what

organisation not only honoured its past achievements but

keeps me turning up every day,” Ms Mills said.

also reaffirmed its commitment to shaping the future of

During the official proceedings Dr Jodi Culbert paid tribute to Nancye Piercy, the longest-standing CEO, whose determination was instrumental in MPHN’s success.

2023-24 Annual Report

healthcare in the region. With a legacy built on passion, dedication, and innovation, MPHN looks forward to continuing its journey towards healthier communities and wellbeing for all.

9

“Congratulations on 30 years of commitment to our region. I am so proud to be a part of some great initiatives.”

Kay Hull AO

“A very nostalgic event for me as the founding coordinator.”

Peter Keith

Implementing our Strategic Plan Since MPHN’s Strategic Plan 2023-2027 was launched in late 2022 the team have continued to deliver on our priorities and importantly, ensure our work has a positive impact on the wellbeing and resilience of our communities.

Our strategic plan aims to make an impact on our communities and provides the roadmap for our activity across the whole organisation.

MPHN’s Executive Integration and Partnerships Narelle Mills said the three focus areas of the plan have guided activities and helped ensure MPHN is undertaking work strategically, collaboratively and with national and state priorities in mind.

“The overarching aim of our first focus area is to seek opportunities to understand the health needs of the region’s priority population groups and invest in activities to help improve their health outcomes,” Ms Mills said.

“We are delivering this through a variety of measures and this year have sought to understand the health challenges for two key population groups; the region’s rainbow community and people who are homeless or at risk of becoming homeless. We are now looking at opportunities to improve health outcomes through design of innovative models of care.”

The second focus area is about how MPHN supports healthcare providers and enhances stronger collaboration.

“As primary care continues to face significant pressures, our teams have focused on providing support to general practice, especially around the implementation of activities under various health reforms including MyMedicare, Urgent Care Services and General Practice Aged Care Incentive, and we know this support and local leadership has been greatly received by our general

Mills said establishing the Innovation Committee as part of the governance of MPHN has been key to driving our approach to innovation across the organisation.

“It has been exciting this year to have a real focus on innovation across a number of forums, and many of the activities outlined in this Annual Report highlight innovative approaches to addressing community needs,” Ms Mills said.

“An important area of focus has also been on the progression of several research partnerships and finalisation of our first Research Strategy. Our role in these research projects in both designing the study and supporting engagement of our local clinicians is critical to ensuring evidence for models of care are locally and rurally based.”

The implementation of our focus areas and priorities are underpinned by four enablers including: •

Effective leadership and governance

•

Our people

establish an allied health engagement framework

•

Authentic engagement and partnerships

and are in the process of establishing an Allied Health

•

Operational agility and excellence

practices,” Ms Mills said.

“In the last financial year, we commenced work to

Advisory Group as well as opportunity to develop a multidisciplinary allied health model as an extension of our WARATAH for Kids program.”

“There have been various activities implemented to strengthen our enablers including investigating the use of AI and other technology as part of our operations, and

Leading innovation and inspiring for positive impact is

to create key engagement positions in the organisation to

the third focus area of MPHN’s Strategic Plan, and Ms

foster partnerships and collaborations,” Ms Mills said.

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2023-24 Annual Report

Focus area

Key achievements delivered or in progress

Invest in communities for improved health outcomes

•

LGBTIQA+ Health Needs Assessment

•

Homelessness Needs Assessment and model development

•

Evaluation of existing models of care that support children, chronic care and

Support providers and enhance collaboration for stronger primary care

mental health •

Development of Aboriginal Health and Wellbeing Strategy

•

Codesign of an Urgent Care Service model

•

Establishment of Lived Experience Advisor Network

•

Development of a Climate Disaster Response Framework

•

Riverina Primary Care Community of Practice

•

CPD Strategy

•

Implementation of Strengthening Medicare health reforms

•

GP Benchmark reports for quality improvement

•

Allied Health Engagement Framework

•

Implementation of specialist services in general practice including endocrinology and cardiology.

Lead innovation and inspire for positive impact

•

Trialling workforce solutions through shared medical appointment models

•

Engagement with Murrumbidgee Health and Knowledge Precinct

•

Key partners in new research activities

•

Implementation of a Digital Health Maturity Assessment across general practice, aged care and allied health

•

Opportunities to showcase achievements nationally at conferences, awards, and in the media

2023-24 Annual Report

13

Contracts

Snapshot of 2023-24

$27,301,255 across

206

contracts

Wagga GP After Hours Service

5,509 122

patient consultations

other allied health services including COPD/asthma education, speech pathology and foot care nurse

8

other, including physiotherapy

practices

First Nations

podiatry

24%

20% 17%

12%

diabetes education

27%

12

Conversations on the Couch events

4

Yarns on the Couch events

160

almost 19,000 occasions of service delivered by ITC, Work it Out and other AOD services delivered by GAMS

Primary healthcare provider support

dietetics

Grants

37

GPs from

Allied health

Conversations on the Couch

home visits

people attended

1,794 37%

practice engagements with primary healthcare providers

face-to-face

$460,000 for 18 GP grants $150,000 for 60 vulnerable population grants $201,000 for 39 COVID immunisation grants $18,000 for 3 suicide prevention grants $155,000 for 28 wellbeing and resilience community grants

50%

increase in users

64%

increase in sessions

61%

increase in page views

Mental health

3,390

mental health clients

42,394

mental health occasions of service

5,405

6,514

occasions of service supporting someone with suicidality

4,792

total patients

Research

clients identify as Aboriginal or Torres Strait Islander

42

general practices signed up for Lumos

18

patients signed up to use Care Monitor

resource pages users sessions page views average pages per session

13

15

vaccination pop ups

591

vaccinations administered

2

clinical trials

2

university adjunct appointments

4

general practices using the HOPE platform

165

patients enrolled in two Commissioned Rehab Programs

78

request pages

information stands at community events

headspace occasions of service

548

clinical pathways

patients screened in 11 pharmacies

457

clinicians and staff trained

901

patients enrolled in the Winter Strategy

Living Well, Your Way

increase in new clinical HealthPathways

In the community

52 12 6 1,670 15,905 60,730 3.82

HealthPathways

49%

In line with our Strategic Plan, we have made a deliberate effort in advocating for the needs of our region – whether that be consumer, community or health professional.

Julie Redway, Executive Commissioning and Operations

being a voice

for our region

In this section Advocating for health in the Murrumbidgee Innovating for impact Driving local research opportunities Understanding the region’s’ health needs Out and about in the community

Minister for Rural and Regional Health The Hon. Emma McBride MP during her visit to the Murrumbidgee in late 2023

Advocating for health in the Murrumbidgee As a health leader, MPHN takes an active role in advocating for the health needs of our communities and health professionals.

Advocacy is a key area of MPHN’s Strategic Plan. It’s a

“Key to being able to deliver on this is working

mechanism for influencing health policy to ensure local

collaboratively with Murrumbidgee Local Health District.

health needs are understood and met. Throughout the

Our strong partnership with MLHD, which is formalised

2023-24 financial year, MPHN has actively highlighted

through a Collaborative Agreement at the Board level,

various challenges faced in the region including

enables us to strengthen service delivery in the region and

workforce, after hours care, and funding.

move towards a one health system approach.”

In March, MPHN, represented by then Acting CEO Narelle

Workforce challenges in the region were also highlighted.

Mills and past CEO Melissa Neal, appeared before the Special Commission of Inquiry into Healthcare Funding in Wagga Wagga. It provided an opportunity to demonstrate the impact of MPHN’s collaborative work and highlight opportunities to further strengthen service delivery, integration and care coordination in the region.

“As an organisation focussed on supporting primary care providers across the region, we have a role in improving coordination of care, commissioning primary care services to meet local population health needs, and supporting capacity building to ensure a sustainable workforce,” Ms Mills said.

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“While we recognise emergency departments can become the default primary care provider in regional and rural areas due to limited or no access to general practitioners (GPs), more work needs to be done to ensure communities can access primary healthcare providers when they need to,” Ms Mills said.

“The delivery of general practice and primary care related services through state funding should only be considered where there is market failure with a focus on restoring services to community to avoid impacting the sustainability of local general practice.”

2023-24 Annual Report

Advocacy in action •

Submission to the Federal Department of Health and Aged Care review of after hours primary care

•

Special Commission of Inquiry into Healthcare Funding in New South Wales

•

NSW Parliamentary Inquiry into Birth Trauma in Wagga Wagga

•

Meetings with Ministers and local members of Parliament

•

Australian National Audit Office (ANAO) audit into the Effectiveness of the Department of Health and Aged Care’s Performance Management of Primary Health Networks

Ms Mills discussed with the Inquiry the importance

MPHN contributed to the National PHN CEO

of timely communication between the hospital and a

Cooperative’s joint submission to the Australian National

person’s GP after a stay in hospital, to ensure timely follow

Audit Office (ANAO) audit into the Effectiveness of the

up by the primary care team.

Department of Health and Aged Care’s Performance

“Data shows that patients who visit their GP within two days of discharge results in 32 percent fewer readmissions within the first week, and a visit in the first four weeks results in seven percent fewer readmissions within 28 days,” she said.

Other opportunities to be innovative and partner under a more formalised approach were also discussed such as joint health planning between MPHN and MLHD. At the federal level, MPHN advocated about the issues and challenges impacting the demand and supply of after hours primary care services in the region with a submission to the Department of Health and Aged Care review of after hours primary care. The submission was guided by feedback from general practice and aged care providers and community. After hours challenges were also discussed directly with Assistant Minister for Rural and Regional Health The Hon. Emma McBride MP late in 2023 when she met with MPHN in Wagga Wagga.

During the ministerial visit, MPHN shared examples of local activities and innovations to help improve system efficiencies and improve health outcomes including the outreach diagnostic heart failure clinics and the Enhancing Paediatrics in Primary Care program. The Minister also spoke with local GPs about some of the challenges of the Strengthening Medicare reforms in relation to MBS billing and MyMedicare.

Management of Primary Health Networks. Published in February 2024, the report’s eight recommendations relate to performance, evaluation and data. In a statement at the time about the report, Acting CEO Narelle Mills said the recommendations relate to performance, evaluation and data and locally MPHN’s programs and services demonstrate improved health outcomes which could be harnessed further by the Department.

“We would like to see the Department harness a reporting system to help turn our healthcare data into information, insights and stories that can improve performance and drive policy,” Ms Mills said.

“Such a system can show what we are doing is working, and when done well it will help provide all stakeholders, including clinicians and patients a better understanding of how the health system works and what it is achieving.

We strongly believe these insights and stories will help improve and inform health policy into the future.”

“Locally our funded activities are supporting and improving the health and wellbeing of people living across the Murrumbidgee.”

Narelle Mills

2023-24 Annual Report

19

Innovating for impact New members and innovative projects were the focus for MPHN’s Clinical Councils and Community Advisory Committee.

After an extensive recruitment strategy, MPHN

Innovation moment

onboarded seven new Community Advisory Committee (CAC) members, and six new Clinical Council members in August 2023. These new voices represent various population groups including veterans, young people, First Nations people, and allied health.

MPHN’s Executive Integration and Partnerships Narelle Mills said hearing voices from a wide range of consumers and health professionals is important to understanding and addressing local health needs.

“With such a diverse range of priority population groups in our region, having a wide range of voices on our advisory groups means we have the opportunity to be across a range of issues at any given time,” Ms Mills said.

“For example, we were able to validate and learn more about the challenges veterans face when accessing healthcare from discussions with the CAC and we have been able to use this provide advice to our GPs about the veterans’ health checks available under Medicare and through the Department of Veterans Affairs.”

In addition to the recruitment drive, each of the four Clinical Councils helped drive innovative projects in their area to address identified needs.

“One of the goals of our Strategic Plan is to lead innovation and inspire for positive impact. We engaged with each of the Clinical Councils to understand what local challenges they were facing and how might we be able to support innovative solutions,” Ms Mills said.

Western Clinical Council is leading a Diabetes Education and Management activity for culturally and linguistically diverse (CALD) communities with the aim to prevent and reduce emergency department presentations for people living with Type 2 diabetes.

“Concerns were raised around a suspected increase in the number of people from CALD backgrounds presenting at the Griffith emergency department with diabetes related complications that could be better managed in the community,” explained Western Clinical Council Chair Dr Bhupinder Kumar.

March 2024, Joint Board, Community Advisory Committee and Clinical Councils meeting

within CALD communities will provide patient-centred knowledge to identify the behaviours to help reduce the risk of developing diabetes, diabetes complications and improve their health outcomes.,” Dr Kumar said.

The two targeted groups for the sessions will be Italian and Pacific Islanders, with multicultural health workers and local community leaders involved to support engagement.

The Wagga Wagga Clinical Council is leading two projects; one to increase the number of MBS 715 health checks for Aboriginal and Torres Strait Islander People by establishing a 715 assessment clinic for children and another to address childhood obesity by introducing the Students as Lifestyle Activists (SALSA) and piloting the

“To address this a Community Diabetes Education

program in The Rock Central School. The SALSA program

Program (CDEP) designed to reduce health disparity

involves university students training year 10 students to

20

2023-24 Annual Report

empower their younger peers about eating healthier foods and being physically active and become SALSA peer leaders.

Membership throughout the 20232024 financial year period

“Both projects are exciting and will support the long-

Community Advisory Committee

term health of both priority population groups –

Rory McKenzie (Chair), Caitlin Reid (Vice Chair), Garth

First Nations People and young people,” said Wagga Wagga Clinical Council Chair Dr Rachael Fikkers.

Similarly, the Border Clinical Council worked on two

Hungerford, Margaret King, John Harper, John Moi, Julie Mecham, Lee Ncube, Stan Warren, Cheney Dewar, Jean van Asperen, Jenny Atkinson, Kathleen

projects relating to continence and prostate cancer.

Stewart, Olivia Jones, Richard Salcole, Fran Day, Keith

“As a group the Border Clinical Council identified a

Brimson (MLHD representative), Peta Larsen (Board

lack of continence services in the region which has a

representative)

Wood, Tegan Lewis (MLHD representative), Setchen

significant impact on the quality of life and reduces the opportunity for an active lifestyle which in turn increases the likelihood of chronic comorbidities,” explained Border Clinical Council Chair Dr Marion

Border Clinical Council Dr Marion Magee (Chair), Lourene Liebenberg

Magee.

(Vice-Chair), Jeremy Carr, Laura Ross, Dr Rachel

MPHN is working with the Continence Foundation

Julianne Whyte, Nicole Smith, Catherine Ryan (Board

of Australia to upskill practice nurses in the region through online training modules and the Rural Doctors Network to fund training through scholarships and establishing a community of

James, Dr Michael Love, Simon Lloyd, Josh Jones, representative) Riverina Clinical Council

practice to support the practice nurses.

Dr Nang Win, Brett Causer, Evan Feather, Lee Francis,

“The Border Clinical Council also commenced

(Board representative)

looking at ways to better support patients who have prostate cancer in the region, including initiatives such as Bins for Blokes which is currently available in the Snowy Valleys and Wagga Wagga,” Dr Magee

Dr Daniel Fry, Luke Peacock, Dr Jacques Scholtz

Wagga Wagga Clinical Council Dr Rachael Fikkers, Carin Lewis, Dr Ayman Shenouda,

said.

Dr Jonathan Ho, Kimberley Aylward, Michael

MPHN also developed a Tell it Well story about

Olivia Kelly, Tom Adamson, Dr Jodi Culbert (Board

the mental health impacts of a prostate cancer diagnosis. Corowa local Dave Harrison graciously shared his story, and it was published in May 2024.

The Riverina Clinical Council identified a need to foster relationships and networking among local healthcare providers, and in June 2024 a Riverina Provider Forum was held. Colleagues from Temora, Cootamundra and Young participated in an educational activity, and an ongoing Riverina

O’Reilly, Nancy Kaur, Sandra Skaf, Tom Schumack, representative) Western Clinical Council Dr Bhupinder Kumar (Chair), Leanne Baulch (Vice Chair), Dr Shazad Ahmed, Emma Kelly, Karen Ingram, Dr Khaled K Bardawil, Leanne Kennedy, Dr Shahid Abbas, Sean Dodd, Dr Alam Yoosuff (Board representative)

Community of Practice has been established.

All clinical council projects were presented to the second joint meeting of the Board, CAC and Clinical Councils in March 2024.

“Its been really exciting to support our Clinical Councils in their projects and looking for innovative solutions for their identified local issues,” Ms Mills said.

2023-24 Annual Report

21

Driving local research opportunities Research is a central enabler for MPHN to deliver on its current Strategic Plan as it provides evidence to inform core functions for the business.

Since 2022, MPHN has been increasing its capacity to

First, in a joint venture with the University of New South

engage in primary healthcare research activities across

Wales, the University of Melbourne, Murrumbidgee Local

the region, and this year, the first research strategy has

Health District, Western Victoria PHN, and the Barwon

been developed.

Health and Ballarat Health Services paediatric team,

MPHN’s Chief Data Officer Dr Jason Bennie (PhD) said he is excited about the organisation’s position to explore the power of research to improve health outcomes for the Murrumbidgee.

“As an academic, research has the potential to enhance healthcare delivery, reduce healthcare costs, improve preventative measures, and trial new treatment approaches,” Dr Bennie said.

“The purpose of our research strategy is to establish how MPHN does research and provide guidance for potential researchers and other stakeholders when considering

MPHN is undertaking the Strengthening Care for Rural Children Clinician Researcher program (SC4RC). Working with the MLHD paediatric team, the research aims to test co-consultations to improve paediatric care in the primary care setting. Locally the team are supported by UNSW Research Assistants co-located with MPHN, with 11 general practices recruited to the trial.

Second, MPHN is one of four PHNs in News South Wales and Queensland taking part in the University of Sydney’s ASPIRE trial, which aims to evaluate a new approach to medication reviews for patients transitioning from hospital care to home settings, with the goal of preventing

engaging with the MPHN in research-related activities.

harm and reducing rehospitalisation rates.

“Ultimately, the vision for research at MPHN is to

ASPIRE’s Medication Safety Pharmacist Research

lead locally driven research to enhance health for our communities, and as we move towards this vision, we will be guided by the region’s health data and needs assessments.”

Key to MPHN’s Research Strategy is leveraging existing relationships, research structures and data, and linking with local universities and the Murrumbidgee Health and

Assistant, employed by MPHN, Melissa Catanzariti said the program aims to support patients with their medication after being discharged from hospital, with a credentialed pharmacist performing a Home Medication Review.

“Medication-related problems are common after hospital admissions and the transition from hospital to home

Knowledge Precinct.

can be a vulnerable time, especially for people who are

“Despite our regional location, a number of universities

Catanzariti said.

have campuses in the Murrumbidgee – many of which have strong health and medicine research capabilities,” Dr

taking multiple medications for multiple conditions,” Ms

“We commenced the clinical component of the trial

Bennie said.

in May 2024 aiming to understand how pharmacist

“I’ve also secured two adjunct appointments with the

health outcomes. So far, we have 24 GP referrers and 12

Centre of Primary Care and Equity, Faculty of Medicine and Health at the University of New South Wales, and at the School of Rural Medicine at Charles Sturt University, which provides MPHN with access to research support, resources and large data sets. All of which expands our

support can improve medicines optimisation and Credentialed Pharmacists performing Home Medicine Reviews and more than 170 patients participating in the trial.

“To get to this point the research project has hosted two

capacity to collaborate and partner in research.”

stakeholder engagement co-design workshops with five

MPHN is already implementing its research strategy with

two general practitioners, and two geriatricians. An

two projects now entering clinical trial phase.

22

community pharmacists, seven hospital pharmacists,

2023-24 Annual Report

“There is much happening in the research space for MPHN, and I’m excited to see this area grow, Murrumbid gee Primar Health Ne y tw Research St ork rategy 2024 Murrumbidgee Primary -2027: Leading loc all Health Network our local com y driven research that enhan munities ces the hea Research Strategy 2024-2027: lth Prep

ared by Dr Leading locally driven research that enhances Jason Benn the health of Chief Data ie (PhD) Officer, Mur rumbidgee our local communities Primary

June 2024

develop and become more prominent at all levels of

Health Netw ork

Prepared by Dr Jason Bennie (PhD) Chief Data Officer, Murrumbidgee Primary Health Network

June 2024

– locally, in New South Wales and nationally. In the longer term it is hoped

expert panel was also established of three GPs and one credentialed pharmacist. All these events were facilitated by the research team from The University of Sydney and

research conducted locally will guide and inform new

all participants were local clinicians.”

models of care that will

As part of the ASPIRE trial, MPHN has established a

support the health needs

directory of accredited local pharmacists (available on the website) who can provide medication reviews for Murrumbidgee residents recently discharged from hospital.

of our region.”

Dr Jason Bennie

Medication reviews are government-funded services provided by GPs and accredited pharmacists to check that a person’s medicines are safe and appropriate. Currently, few people who might benefit are offered a medication review when they leave hospital.

Two clinical trials: Strengthening Care for Rural Children (SC4RC) •

11 General Practices involved in the clinical trial

ASPIRE (A Systems aPproach to enhancing community-based medication REview) •

More than 150 patients and 11 credentialed

Two university Adjunct appointments •

University of New South Wales

•

Charles Sturt University

pharmacists involved in clinical trial

2023-24 Annual Report

23

MPHN employees Dr Jason Bennie, Tom Parker, Ryan Du Toit and Alanah Christie at Conversations on the Couch in Wagga Wagga

Understanding the region’s health needs

Innovation moment

By actively working to understand local health needs, MPHN can tailor healthcare programs for maximum impact, improving health outcomes, and strengthening community engagement and trust.

This year MPHN’s Conversations on the Couch program

MPHN integrates Conversations on the Couch insights

continued gathering valuable insights on local healthcare

into our Health Needs Assessment to inform future

needs and challenges, with events held in Temora,

service planning. Residents are encouraged to continue

Berrigan, Deniliquin, Jerilderie, Wagga Wagga, Coolamon,

sharing their thoughts on healthcare by participating in

Griffith, West Wyalong, Narrandera, Leeton, and Tumut.

MPHN’s anonymous Health Needs Assessment survey.

Participants across all locations reported challenges

Community Engagement Coordinator Tom Parker said

in accessing GPs and specialist services, including

Conversations on the Couch gave MPHN a unique insight.

long wait times and the need to travel to larger towns.

Transportation issues were also raised by participants, such as the lack of local taxi services. There were also concerns about the limited availability of mental health services and the financial burden of healthcare expenses.

Despite these challenges, participants expressed strong appreciation for the dedication of local healthcare professionals and the positive impact of bulk billing.

Collectively, this feedback highlighted the need for better continuity of care, improved follow-up on medical tests, and more support for those facing domestic and family violence, problematic substance use, and the rising cost

“Many Murrumbidgee communities face similar challenges but have their own nuances that you can only understand by listening to people with lived experience,” Mr Parker said.

“It’s satisfying to be able to connect people to services they were not aware of.”

Tom Parker

of living.

24

2023-24 Annual Report

MPHN’s Yarns on the Couch events in Leeton, Griffith, and West Wyalong provided First Nations community members with a safe space to share their personal experiences.

Key issues raised included a lack of reliable transport, difficulties with hospital discharge and follow-up care, and inadequate mental health and problematic substance use support. Attendees also highlighted the need for local Aboriginal Medical Services (AMS) in Leeton and West Wyalong, as well as a lack of bulk billing. These events underscored the need for improved local healthcare support and accessibility.

Aboriginal Health and Wellbeing Manager Maxine Honeysett said ‘Yarns’ was a great platform to build connections with communities, Elders, and services.

“To listen and yarn with the community members, to be able to feedback their concerns and then touch base about the process and where it is up to means we can be part of their community support network,” Ms Honeysett said.

One of MPHN’s key findings over the last few years has been the rise of homelessness and issues with housing affordability and lack of affordable rental properties across the Murrumbidgee. This year MPHN commissioned Beacon Strategies to undertake a homelessness-specific Health Needs Assessment (HNA). The HNA involved stakeholder engagement session with representatives from housing, social and heath sectors, with findings triangulated with population health and service utilisation data.

The HNA identified several areas of need including affordable and timely access to primary and specialist care, and opportunities to explore outreach models bringing services to where people are living. MPHN secured department funding to deliver a Homelessness Health Support Program in 2024/25 and is looking forward to delivering this program in the coming year.

MPHN Acting CEO Narelle Mills with LHAC member Dave Harrison at the LHAC Forum in Leeton

Working closely with our region’s Local Health Advisory Committees (LHACs) is an important part of MPHN’s strategy to maintain an understanding of community healthcare experiences. This year, in collaboration with the Murrumbidgee Local Health District (MLHD), two pivotal LHAC Forums were held in Deniliquin and Leeton. These events brought together LHAC members, healthcare leaders, and community representatives to discuss strategies for strengthening community advocacy and fostering innovation. The forums also reinforced the importance of strong partnerships between LHACs, MPHN, and MLHD, ensuring community voices stay at the heart of decision-making processes.

Duanne Attree, Chair of MPHN’s Innovation Committee, reflected on the Leeton LHAC Forum event’s success in fostering community-focused partnerships.

“It shows the best of what can happen when you really turn the system towards community, patients and consumers.”

Duanne Attree By listening to and acting on the insights gathered from our community engagement, MPHN continues to deepen our understanding of what our communities truly need, ensuring our efforts are both relevant and impactful.

Yarns on the Couch in Narrandera

2023-24 Annual Report

25

Out and about in the community

Innovation moment

MPHN has been travelling across the Murrumbidgee engaging with communities, providing free vaccinations and sharing vital health information with people in need.

Over the past year, our team has taken part in a wide

“Meeting with people in their own communities helps us

range of community events, from celebrations, health

understand their unique needs, connect them with health

and wellness events such as winter markets and family

service information, and offer free vaccinations to those

fun days, and other outreach events, reinforcing our

who may be vulnerable or have fallen behind with their

commitment to enhancing local health and wellbeing.

healthcare,” Ms Anderson said.

MPHN remains actively engaged with our First Nations

“It’s also a great environment to chat about mental health

community through local events, including NAIDOC

and get people connected with relevant healthcare

Week celebrations and National Reconciliation Week. Our

providers. Having these relaxed conversations helps us

participation in these important events helps staff to build

foster a healthier and more informed community.”

strong and respectful relationships with our First Nations communities and to better understand culture and needs.

MPHN’s Healthy Ageing and Palliative Care team has been engaging with communities to provide essential

A significant focus of our community engagement has

information and resources on aged care and palliative

been ensuring access to immunisations. Throughout

care. The team’s efforts have focused on raising

the year, we organised multiple pop-up vaccination

awareness, offering support, and helping ensure people

clinics which delivered a range of free vaccines, including

have the necessary information to make informed

COVID-19, influenza, and Japanese encephalitis (JE).

decisions about their health and wellbeing as they age.

Events like the Henty Machinery Field Days, Big Picnic,

In October 2023, the team participated in the Aged

and Junee International Women’s Day Expo allowed

Persons Information Day in Barham, sharing insights on

MPHN to connect with the community. In December

aged care and future planning. In February, they attended

2023, MPHN sponsored a Foodbank pop-up event in

the Unlocking Hope event in Tocumwal, focusing on

Wagga Wagga, which provided crucial food relief ahead

dementia and palliative care, and contributed to the

of the holiday season, distributing eight tonnes of fresh

OM:NI Community Information Session in Wagga Wagga,

produce to hundreds of families. Free health checks were

which was recognised by State Member for Wagga Wagga

also offered at the event.

Dr Joe McGirr in parliament.

MPHN’s Clinical Programs and Emergency Response

MPHN had the privilege of hosting the Senior’s Week

Manager Peta Anderson said the benefits of being active

expo in Wagga Wagga in March 2024, which focused on

in the community are immeasurable.

holistic wellbeing for seniors. MPHN’s Healthy Ageing and

2023 Henty Machinery Field Days

OM:NI Community Information Session in Wagga Wagga

26

2023-24 Annual Report

Palliative Care Manager Shelley Gledhill said the expo helped people find out how to live an active and healthy life in their golden years.

“This chapter of your life can be one of the happiest and most enjoyable if you take time to plan ahead,” Ms Gledhill said.

“By understanding how to protect and improve your health, how to maintain your independence, and exactly what you want your retirement years to look like, you’ll be able to set your own course.”

Shelley Gledhill

Griffith Aged Care Expo

In June, the team engaged in an Information Session for Seniors in Wagga Wagga, discussing local aged care services, and joined the Wagga Wagga Elder Abuse Committee to raise awareness on World Elder Abuse Awareness Day. Other key events attended this year included expos in Griffith, Junee, Tumbarumba, and Wagga Wagga, as well as events in Tocumwal and Cootamundra.

Healthy Ageing Project Officer Jane Gerhard said it was satisfying to be able to empower people to be informed MPHN team at the Senior’s Week expo (Wise + Well Expo)

and make decisions that suit them.

“People often think they must follow what they’ve seen in the media or heard from others, so it’s important to let them know the available options and equip them with the knowledge they need to make decisions that suit them”’ Ms Gerhard said.

“It’s always rewarding having chats with people and hearing their stories. All those little bits of information help direct what we’re going to do, what supports we’re going to commission to fill those gaps and help us advocate on the communities’ behalf with some of those needs that aren’t met. Having the opportunity to take time out and have conversations with people informs

Peta Anderson interviewed by the media at the Senior’s Week Expo

2023-24 Annual Report

MPHN’s work.”

27

Each quarter we see so many good news stories from our commissioned service providers about the program they are delivering. It’s heartwarming to know we are truly making a difference to the health and lives of people living in the Murrumbidgee.

Janelle Dufty, Senior Manager Commissioning

making a difference In this section Child, maternal and women’s health First Nations health Caring for our seniors Supporting mental health, and alcohol and other drugs needs State recognition for suicide prevention work in the Murrumbidgee Enhancing lives: our commitment to health and wellbeing Care in the after hours period doesn’t always need to be an emergency

Child, maternal and women’s health MPHN is passionate about supporting the health and wellbeing of families by helping to provide care where it’s needed most. Through our commitment to child, maternal, and women’s health, we’ve seen firsthand the difference compassionate support can make in people’s lives.

MPHN’s Senior Manager of Commissioning, Janelle Dufty,

her. Thanks to the comprehensive support from the

emphasises the importance of investing in families across

Women’s Wellness and Recovery team, Rachel developed

the region.

a relapse prevention plan and took part in parenting

“When we invest in the health and wellbeing of women, parents, and children, we’re helping to create a community where everyone can flourish,” Ms Dufty said.

programs, which enabled her to make positive changes in her life. Her dedication paid off, and her two older children were returned to her care – a testament to the success of the program.

“We want to use our resources

Another initiative making a difference is WARATAH for

to help make a meaningful

Kids. This program helps young children who are facing developmental delays by facilitating assessments and

difference in people’s lives, so

referrals to allied health services. This year, over the

they know they’re not alone on

timely assessments and support. One success story is

their journey.”

Janelle Dufty Every family’s journey is unique, and the arrival of a new baby often brings both joy and stress. MPHN partners with Gidget House Wagga Wagga, which provides free

course of 42 clinics, 109 children were seen, receiving that of 7-year-old Ollie*, who was struggling with sensory processing, emotional regulation, and behavioural issues.

Through WARATAH for Kids, Ollie was referred to an occupational therapist (OT) for a comprehensive intake and assessment. With the OT’s guidance, Ollie’s family received tailored strategies and referrals, ensuring timely and coordinated care that allowed Ollie to thrive.

psychological counselling for expectant and new parents experiencing perinatal depression and anxiety (PNDA).

This support is vital, recognising the emotional toll PNDA can take on families. In the 2023-24 financial year, Gidget House delivered 76 consultations, dedicated to enhancing parents’ wellbeing through professional and empathetic care.

MPHN’s work extends beyond psychological care, supporting critical programs designed to help pregnant women and new mothers grappling with substance abuse.

One such initiative is the Calvary Women’s Wellness and Recovery Program, which provides intensive Alcohol and Other Drugs (AOD) services to women who are either pregnant or caring for young children. This year, the program helped 141 clients over 167 episodes of care.

Rachel’s* story highlights the transformative effect of this program. The young mother of three sought help for multi-substance use in mid-2023, having just completed a residential rehab program. At that time, two of her children were in care, while her youngest remained with 30

Wagga Women’s Health Centre

2023-24 Annual Report

Wagga Wagga

Griffith

Headspace Griffith and Wagga Wagga

42

1,298

clinics

109

total clients

children supported

1,483

episodes of care

8,313

occasions of service

Women’s Wellness and Recovery

141

total clients

167

76

episodes of care

consultations

The support MPHN provides also extends to women

headspace Griffith has assisted 288 clients with 321

facing crises. The Wagga Women’s Health Centre, which

episodes of care, delivering 2,901 occasions of service.

MPHN proudly supports, offers services in reproductive health, mental health, crisis assistance, and education.

This year, 2021 individual services were delivered. Fiona’s* story is a powerful example of the difference the centre can make. After reaching out for afterhours counselling in early 2023, Fiona, who had been struggling with increasing control from her partner, began working with a trauma-informed counsellor via telehealth. Over time, she addressed her childhood trauma and built coping strategies, which enabled her to transition to independent living.

Young people in the region are also a key focus for MPHN. headspace Wagga Wagga and headspace Griffith, both supported by MPHN, offer essential mental health services for youth. In the past year, headspace Wagga Wagga has supported 1,010 clients through 1,162 episodes

A recent success story from headspace Wagga Wagga involves Jayden*, who had been struggling with focus and was referred to the centre’s work and study specialists.

After an assessment by a psychiatrist, Jayden was diagnosed with ADHD and began medication. Over the course of two months, he made remarkable progress; completing his resume, obtaining his driver’s licence, and preparing to start a mechanic apprenticeship after successfully completing a work trial.

From supporting parents through PNDA to helping young people thrive, MPHN’s initiatives are making a lasting impact on the region’s families, ensuring everyone has the opportunity to lead a healthy, supported life. * Names changed

of care, providing 5,412 occasions of service. Meanwhile,

2023-24 Annual Report

31

NAIDOC Week activities at MPHN

First Nations health MPHN remains dedicated to enhancing the health and wellbeing of First Nations peoples through targeted initiatives and strong community partnerships.

MPHN continues to provide crucial funding to support

AOD services provided by Murrin Bridge AMS, Wagga

First Nations Alcohol and Other Drugs (AOD) programs.

RivMed, and Albury AWAHS, collectively offering local

This ongoing investment ensures culturally appropriate

and outreach support across the Riverina region. This year,

care and resources are available to address the unique

the GAMS AOD program helped 495 clients.

challenges faced by First Nations communities.

One notable experience involved a female client who

The Work It Out program, delivered by Pathways

faced significant challenges due to ongoing substance

Murrumbidgee, provides AOD intervention services

use and domestic violence, leading to her children

for Aboriginal and Torres Strait Islander people facing

being placed in the care of kinship carers. Through

challenges engaging in employment or education due

active engagement with the GAMS AOD worker and

to issues with substance use. This year, the program

collaborative support from the Social and Emotional

saw 100 clients, delivering 112 episodes of care. Mark*

Wellbeing worker, the client has successfully abstained

joined the program in 2023 with alcohol dependency

from substance misuse. She is now being assisted to

and legal issues. Through regular counselling and

secure independent accommodation and is working

case management, he received support with legal aid,

towards rekindling her relationship with her children.

motivational interviewing, cognitive behavioural therapy (CBT), and alcohol management strategies. Mark* successfully reduced his alcohol intake, abstained from other substances, found employment, and regained his driver’s licence. He is still engaged with the program and is pursuing future employment opportunities.

MPHN also funds the Integrated Team Care program to enhance primary healthcare access for First Nations people through local Aboriginal Medical Services and Marathon Health Ltd. During the year, the program delivered 15,708 services, both face-to-face and telehealth. Brian* was referred to the Integrated Team

The Griffith Aboriginal Medical Service (GAMS) provides

Care Program by his GP due to multiple complex

a vital AOD program, which is part of a broader Regional

health issues, including chronic obstructive pulmonary

Drug & Alcohol support network. This network includes

32

2023-24 Annual Report

MPHN team at Erin Earth, May 2024

Wiradjuri-Ngunnawal Elder Aunty Mary Atkinson at MPHN’s Reconciliation Action Plan launch, December 2023

disease, anxiety, and malnutrition. He struggled with

“By teaming up with local groups and backing programs

low health literacy and managing his medications, while

that tackle important issues like mental health, chronic

facing barriers to accessing specialist care. Through

disease, and substance abuse, we’re making a difference

regular support from a care coordinator, Brian received

to the health and wellbeing of First Nations people in our

help with understanding his health needs, medication

region,” Ms Honeysett said.

management, and accessing essential services. He now feels more confident in managing his health.

“I am feeling so much better about everything. My care coordinator has helped me with a lot, and my daily life is a lot easier. I especially appreciate the help with managing my medical appointments and the help that I am now getting at home,” Brian said.

“Our aim is to make sure everyone has access to the healthcare and support they need to live their best life.”

This year, the Reconciliation Action Plan (RAP) Working Group made significant progress in advancing reconciliation within our organisation. Key achievements include establishing a Terms of Reference and updating MPHN’s human resources policies to enhance and

MPHN is a proud member of the Murrumbidgee

promote Indigenous participation. The group also

Aboriginal Health Consortium (the Consortium) which

developed internal reporting mechanisms to monitor RAP

addresses critical areas such as mental health, alcohol

activities and explored membership with Supply Nation.

and other drugs (AOD), chronic disease, maternal health, and family violence. The Consortium closely monitors progress against key performance indicators outlined in the AHC Regional Plan, ensuring efforts are aligned with the broader goal of enhancing the social, emotional, and cultural wellbeing of the entire community.

Aboriginal Health and Wellbeing Manager Maxine Honeysett said these initiatives underscore MPHN’s commitment to fostering an inclusive and supportive environment for Aboriginal and Torres Strait Islander staff and communities.

Efforts to increase awareness and participation in National Reconciliation Week and NAIDOC Week were successful, education on the effects of racism was extended to all staff, and cultural protocols, including Welcome to Country and Acknowledgement of Country, were developed and promoted.

The group also reviewed Aboriginal and Torres Strait Islander representation across governance structures and explored opportunities to engage First Nations cultural advisors for the MPHN Board.

The MPHN team attended NAIDOC week celebrations in Wagga Wagga

2023-24 Annual Report

33

Caring for our seniors MPHN continued its commitment to improving the lives of older Murrumbidgee residents by delivering innovative programs and services that support their health, wellbeing, and dignity as they age.

Among the various ways MPHN supports graceful ageing

“As people age, they often face physical and social

are programs like Vitality Passport and care finder,

challenges that can affect their independence. We’re

through the Murrumbidgee Aged Care Consortium, and

committed to keeping people connected, reducing the risk

with partnerships with Dementia Australia.

of preventable health issues, and enhancing their overall

Healthy Ageing and Palliative Care Manager Shelley Gledhill said it was critical to deliver the right care as people age.

“By supporting people’s health and wellbeing,

wellbeing. In doing so, we’re playing our part in fostering a more compassionate, inclusive, and healthy community.”

Vitality Passport, delivered by Back on Track Physiotherapy, aims to reduce or halt the progression of frailty and falls in older people. In 2023-24, Vitality Passport supported 266 participants living in the community and 133 participants in residential aged care

we honour their

homes, helping to improve overall health and wellbeing.

contributions and help

Margaret*, a participant managing significant frailty and

them maintain dignity

in her condition after completing the program. Her

and quality of life.”

limited exercise capacity, saw a marked improvement respiratory training enhanced her walking tolerance, reducing her shortness of breath. Inspired by her

Shelley Gledhill

Jane A and Jane G from MPHN with Ash and Tracey from Marathon Health representing the care finder program at the Griffith Senior’s Expo

34

2023-24 Annual Report

Murrumbidgee Aged Care Consortium workshop

progress, Margaret* joined the Pulmonary and Cardiac Rehabilitation program, continuing to make strides in her health and fitness.

“My lung specialist [...] was very pleased with the improvement of my lungs at my last appointment. I am extremely grateful [...] and I thoroughly recommend this Vitality Passport course to anyone,” Margaret said.

MPHN also supports the care finder program, delivered by Marathon Health and Uniting, which helps older members of our community who struggle to access services and lack an existing support network. The care finder program assisted 357 clients this year, ensuring these vulnerable older people received the support they needed to navigate complex health and social systems.

Care finder proved invaluable for Mark*, a man living with lung cancer in a regional town, who experienced memory loss due to cancer spreading to his brain. With no nearby family, Mark* turned to the care finder team, who supported his move into residential care and helped him reconnect with old friends.

One of Mark’s* final wishes was to reunite with his estranged brothers before his passing. The care finder team tracked down one brother interstate, and soon both brothers were able to visit, profoundly improving Mark’s* mental wellbeing. He has since expressed deep appreciation for the support provided through care finder, which has made a positive impact on his quality of life.

The Murrumbidgee Aged Care Consortium, a MPHN initiative, focuses on improving coordination and access to timely and appropriate care for older people and their carers. Key achievements over the past year include promoting professional development, hosting a workshop

2023-24 Annual Report

to set impactful goals for 2024, recruiting new members with lived experience, and finding opportunities to improve service delivery.

MPHN has developed comprehensive dementia care resources in collaboration with LHD specialists and geriatricians. These resources, available on HealthPathways and other platforms, cover a wide range of topics, including screening, prevention, medications, referrals, and management of behavioural and psychological symptoms. They also offer guidance on driver assessments, cognitive impairment, and neurological exams for patients with possible dementia.

In collaboration with Dementia Australia, MPHN created a dementia support page providing healthcare professionals with referral information and resources tailored to multicultural and First Nations patients, as well as carer support.

MPHN has also commissioned several programs to improve access and quality of care for older people in community and residential care, including the Dementia Capacity Building Program, Medication Management toolkit for Palliating In Place (MM-PIP), GP quality improvement for palliative care patients, and Palliative Care Outcomes Collaborative (PCOC) in general practice.

Through the Aged Care Program, MPHN continues to support residential aged care homes across the region.

MPHN delivered a new training package to providers, focused on the Murrumbidgee Acute Care Decision Guidelines and telehealth training modules. Additionally, MPHN continues to support aged care homes with Basecamp and a well-received Community of Practice, helping to unify providers across the region.

35

Supporting mental health, and alcohol and other drugs needs From early intervention to intensive treatment, MPHN-commissioned programs offer critical support, helping people manage their challenges and find stability.

MPHN has been making significant strides in addressing

Mental Health, Alcohol and Other Drugs Manager Maja

mental health and alcohol and other drugs (AOD) needs

Asmus said MPHN’s work in the mental health and AOD

across the region, working closely with local service

space focuses on giving people a sense of hope and a

providers to ensure comprehensive care for people of all

pathway forward.

ages.

One standout initiative is the MyStep to Mental Wellbeing (MyStep) program, which offers a range of mental health services, including early intervention and psychological treatment. Over the past year, MyStep has delivered 16,356 services, proving its vital role in the community.

One particularly moving story is that of a man who had recently relocated to the Murrumbidgee region and found himself isolated, with his only interactions taking place during brief shopping trips. Through MyStep, he was connected with a peer support worker, and their regular phone conversations provided him with a safe space to open up. Gradually, his confidence grew, culminating in a significant moment when he met his support worker for coffee at a local café. This breakthrough led him to set personal goals like visiting the Men’s Shed and visiting a local music shop, where he began forming new friendships. The ongoing support he received through

“We want to connect people with the right support in a way that respects their unique needs,” Ms Asmus said.

“It’s amazing to see the work our providers do, supporting people to rebuild their lives and regain confidence, and the ripple effect that has on the wider community around them. That’s why we work so well together; we’re all passionate about making a real difference.”

MyStep has been life changing.

Maja Asmus

MPHN also supports headspace, an essential resource

Another vital service MPHN supports is Sunflower House,

for young people in Wagga Wagga and Griffith. headspace

a psychosocial provider in Wagga Wagga helping people

offers support in areas like mental and physical health,

with mental illness navigate their recovery journey.

AOD, and assistance with work and study. Among those

Sunflower House not only delivers mental health services

helped was a young woman in her late teens who had

but also raises awareness of the rights of people facing

been grappling with anxiety, stress, and episodes of self-

mental health challenges, empowering them to engage

harm. Initially reluctant to engage due to past negative

in work and community life. This year, Sunflower House

experiences with therapy, she slowly began to trust

cared for 548 clients, including one man whose severe

the process. After 20 tailored sessions, she developed

anxiety had severely impacted his daily life. With the

strategies to manage her emotions and, despite some

guidance of Sunflower House staff, he learned capacity-

setbacks, has made considerable progress. Six months

building techniques such as meal planning, shopping, and

post-treatment, she remains relapse-free, a testament to

cooking. His progress was marked by a personal victory,

the lasting impact of the program.

successfully preparing a pizza on his own, highlighting the service’s commitment to fostering independence and self-confidence.

36

2023-24 Annual Report

MPHN’s support extends to various AOD services across the region, including the Women’s Wellness and Recovery Program, the Murrumbidgee Pathways AOD

16,356

Enhancement (Pre and Post Treatment Service), and the Griffith Aboriginal Medical Service (GAMS) Alcohol and

occasions of service

Other Drugs program. A recent success story from GAMS features a woman on a challenging journey to overcome substance misuse. With the ongoing support of an AOD worker, she has managed to abstain from substance use and is now preparing for further treatment, a promising step in her recovery journey.

548

Through its strong collaboration with service providers, MPHN continues to play a pivotal role in helping people

clients

facing mental health and AOD challenges, enabling them to regain control of their lives and thrive.

Murrumbidgee Pathways AOD Enhancement

75

clients

80

episodes of care

Emma Bromham and Maja Asmus at the Deniliquin Mind Your Mental Health Mini Conference, October 2023

2023-24 Annual Report

37

Wellways Acting NSW/ACT General Manager Zoe Evans joined MPHN’s Suicide Prevention Regional Response Coordinator Seryn Adams to accept the Communities in Action Award on behalf of the Murrumbidgee Local Response Group at the NSW LiFE Awards in Sydney.

State recognition for suicide prevention work in the Murrumbidgee MPHN is dedicated to enhancing the wellbeing of people and communities through comprehensive initiatives focused on suicide prevention, aftercare, and postvention support.

As a proud member of the Murrumbidgee Local Response

recognised for its outstanding contributions to suicide

Group, MPHN recently celebrated a major milestone. The

prevention across the region. The LiFE Awards celebrate

group was honoured with the prestigious Communities

innovative initiatives in suicide prevention, providing a

in Action Award at the 2024 NSW LiFE Awards, hosted

platform to share best practices and effective solutions.

by Suicide Prevention Australia. Alongside partners

The award ceremony highlighted the group’s dedication to

Murrumbidgee Local Health District (MLHD), NSW

delivering prompt, coordinated, and effective responses

Police, NSW Ambulance, and Wellways, the group was

to suicide events and critical incidents across the Murrumbidgee region.

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2023-24 Annual Report

In addition to this award, the group also received

In a complementary effort, MPHN also commissions The

nominations for the Outstanding Contribution Award,

Way Back Support Service, an aftercare model delivered

acknowledging impactful initiatives like the Frontline

by Wellways, designed to support people at high risk of

Guide and the STOP Campaign. These efforts have played

suicide. This service provides essential support during

a significant role in advancing suicide prevention and

particularly vulnerable times, helping people stay safe

aftercare strategies and resources throughout the region.

and connected to community resources. By focusing on

Wellways Acting NSW/ACT General Manager Zoe Evans, who travelled to Sydney with MPHN’s Suicide Response Coordinator, Seryn Adams, to accept the award on behalf of the group, said the accolade showcases the positive impact that can be achieved through collaboration with various partners and the community.

“With a collaborative approach we can provide carefully tailored support for impacted families and the wider community, and in doing so, prevent further loss of life,” Ms Evans said.

“I’m so proud of this achievement

those who’ve recently attempted suicide or are at risk without adequate support, The Way Back Support Service ensures that cost isn’t a barrier, offering care at no charge.

In just the past year, the service provided 5,456 episodes of care, a lifeline for many.

There are countless stories that underscore the power of this service. In one case, a support coordinator worked with a teenager at risk of juvenile detention.

By collaborating with the young person, their family, local police, and Aboriginal liaison officers, the support coordinator helped steer the situation towards a positive outcome, allowing the teenager to remain in the community with ongoing support from Wellways.

and as a group we’re going to

Another key component of MPHN’s suicide prevention

further develop and build on our

work is the Peer Workforce activity within The Way Back program. This initiative brings the lived experiences of

support for suicide prevention

peer workers into the fold, offering clients an added layer

and aftercare across the

navigate their recovery, while also connecting carers and

Murrumbidgee.”

Zoe Evans One of the key pillars of this effort is the After Suicide Support Program, a trauma-informed, non-clinical coordination service. Delivered by support coordinators and peer workers, this program provides essential support to families, friends, workplaces, and communities affected by suicide loss, no matter when or where it occurred.

Flexibility is at the heart of the program, allowing participants to access support as their needs evolve, without a set end date. With interventions happening mainly in homes or community settings, the program creates a comforting and supportive environment, reducing the risk of further suicide-related behaviours and negative health outcomes.

of support. Peer workers help people build resilience and families to valuable community resources.

The peer support model is transformative, as one recent participant discovered. Struggling with social anxiety and panic attacks that kept them from engaging in everyday activities like grocery shopping or socialising, the participant was paired with a peer worker who had faced similar challenges. Through regular walks and attending community events together, the participant slowly began to rebuild their confidence. Today, they’re dreaming of starting their own business and even a local philosophy group, a testament to the power of peer support.

MPHN’s initiatives, whether it’s aftercare, postvention, or suicide prevention, are built on a foundation of collaboration, compassion, and community. By working together with local organisations, families, and individuals, MPHN is making sure that when people need support the most, they won’t have to face their struggles alone.

2023-24 Annual Report

39

Enhancing lives: our commitment to health and wellbeing Fostering healthy lifestyles across the community is key to preventing illness and enhancing quality of life.

At MPHN, we recognise personal circumstances and

The ICC program plays a critical role in managing chronic

unfamiliarity with healthcare providers can deeply impact

disease by connecting people with care coordinators who

a person’s ability to maintain their health. That’s why we

collaborate with families and carers, offering tailored

continue to invest in services and programs that promote

support, information, and referrals to necessary services.

wellbeing and resilience while ensuring additional care is

This approach promotes self-management and health

accessible where it’s needed most.

literacy, focusing on reducing the risk of unplanned

A prime example of this commitment is the Murrumbidgee WARATAH program, run by Marathon Health, which ensures people with chronic conditions, particularly those facing barriers to care, can access vital allied health services throughout the region. By working with local allied health providers and general practices,

hospital visits. Meanwhile, the Health Navigator Support service begins with a personalised health and wellbeing review, creating a care plan based on each person’s strengths, needs, and preferences. These plans link people with community services while also leveraging existing support systems, such as family and friends.

the program identifies and addresses service gaps. This

MPHN Contracts Manager Christina Eastall said such

year, the WARATAH program delivered 5,755 occasions of

programs are vital to ensure vulnerable members of our

service across dietetics, podiatry, diabetes education, and

community don’t fall through gaps in the health system.

physiotherapy. A total of 1,582 new clients received care, with the program supporting 2,592 people overall.

“It’s easy to forget how

An extension of this initiative, Waratah for Kids, has

overwhelming the health system

also seen significant progress in assisting children and their families. This program has brought occupational and speech therapy screening clinics to several towns, including Wagga, Gundagai, Hay, Leeton, and Deniliquin.

Among the many success stories is Jennifer*, a two-yearold referred to the Waratah for Kids program for speech delays and other developmental challenges. The support she received included strategies for toileting and sensory development, offering much-needed guidance while her family continues to navigate service waitlists.

Beyond the WARATAH program, MPHN also funds the Integrated Care Coordination (ICC) and Health Navigator Support services, both delivered by Marathon Health.

These programs are designed to guide people through the often-complex healthcare system, specifically targeting people with chronic conditions and complex health needs.

This year, the ICC program delivered 3,853 services for 121 clients, while the Health Navigator program provided 1,261 services to 97 clients.

can be, particularly if you’re dealing with other complications in your life, and if you don’t have a strong support system around you.”

Christina Eastall “We continue to invest in these programs because we believe everyone deserves access to the healthcare they need, and everyone deserves dignity, respect, and care in times of illness and hardship.”

This year, MPHN also focused on educating the community about staying well during seasonal changes.

In September, as part of the Thunderstorm Asthma Collaborative, we launched our annual campaign to raise awareness of the increased risk of asthma flare-ups during spring thunderstorms. The campaign highlighted the

40

2023-24 Annual Report

Spring Thunderstorm Asthma launch

importance of managing conditions like hay fever and

conditions to develop health plans. These efforts were

asthma with help from healthcare professionals, while

designed to empower the community to stay healthy

also featuring community stories underscoring the value

through the colder months.

of keeping asthma action plans up to date.

By prioritising health and wellbeing initiatives, MPHN

To prepare for winter, we rolled out our Winter Strategy

is enhancing quality of life for communities across the

campaign, which encouraged early flu vaccinations,

Murrumbidgee region, creating a supportive environment

emphasised the need for up-to-date childhood

where everyone can thrive and enjoy a healthier future

immunisations, and advised people with chronic

together.

Winter Strategy campaign

Help stop the spread.

Get vaccinated and practice good hygiene.

Talk to your doctor or learn more at mphn.org.au Proudly funded by

2023-24 Annual Report

41

Care in the after hours period doesn’t need to be for an emergency MPHN is dedicated to ensuring community members have access to essential healthcare services during the after-hours period, providing vital support when it is needed most.

For more than two decades, the Wagga GP After Hours

for residents of aged care facilities. This year alone,

Service (WGPAHS) has provided reliable, urgent medical

the service conducted 5,509 patient consultations and

care outside regular clinic hours, ensuring Wagga Wagga

facilitated 122 home visits, with 37 dedicated general

residents have access to essential health services when

practitioners from eight different practices supporting

they need them most. Operated by MPHN in collaboration

this essential service.

with local general practices and GPs, the service offers a vital alternative to emergency departments for urgent non-life-threatening medical issues.

Now in its 21st year, the WGPAHS operates during evenings, weekends, and public holidays, and provides both clinic-based consultations and urgent home visits

After Hours and Urgent Care Program Manager Karen Jones said the service offers peace of mind.

“No one plans to become unwell at night or on a public holiday, but if it does happen, it’s reassuring to know you have options.”

Karen Jones

MPHN’s firsthealth Board Chair Dr Jodi Culbert with former Wagga GP After Hours Service Chair Dr Hanaa Mishricky.

Celebrating 10 years of service: •

Dr Anna Gear

•

Dr Patricia Overliet

Wagga GP After Hours Service

5,509

patient consultations

122

home visits

Special thanks to the following practices: •

Blamey Street Surgery

•

Glenrock Country Practice

•

Hammond Health

•

Kooringal Medical Centre

•

Morgan Street Healthcare

•

Nova Health

•

Riverina Family Medicine

•

Wagga Wagga Medical Centre

42

37

general practitioners

6

receptionists

8

practices

2023-24 Annual Report

Toni Preuss and Lesley Lemon media interview for Wagga GP After Hours Service

“The Wagga GP After Hours Service ensures people have

unable to secure an appointment with the Wagga service

access to quality care when they need it. It’s rewarding

were seamlessly connected with telehealth support and

to see the difference we make for patients, especially

booked into available timeslots.

those who might otherwise end up in the emergency department.”

By offering an accessible option for after-hours care, the WGPAHS helps reduce the strain on local emergency departments and ensures that vulnerable community members can receive prompt care. The commitment of the general practitioners involved in this service is invaluable, offering peace of mind to patients and their families.

This initiative’s success reflects the strength of MPHN’s partnerships within the healthcare community, fostering a collaborative approach to meeting health needs in the Murrumbidgee.

Chair of the Wagga GP After Hours Service, Dr Katherine Smith, expressed her gratitude for the contributions of the service’s long-time Chair, Dr Hanaa Mishricky, who stepped down in February this year.

“Dr Mishricky’s leadership has been invaluable in shaping the Wagga GP After Hours Service into the trusted and essential community resource it is today,” Dr Smith said.

“Her dedication has made a lasting impact, and we are deeply grateful for her service. I look forward to continuing this vital work alongside our dedicated team of GPs to ensure the community can access the care they need, when they need it most.”

Following negotiations with the Department of Health and Aged Care, MPHN has successfully extended the HealthAccess contract through to 30 June 2025.

Senior Manager Integration Toni Preuss said the HealthAccess service is becoming increasingly important to the region.

“Telehealth serves as an important backup for people whose health concerns mean they can’t wait until the next day to see their GP,” Ms Preuss said.

“We’re pleased with the community’s uptake of the service and plan to expand the areas covered by HealthAccess in the near future.”

In 2023-24, MPHN supported the Wagga Women’s Health Centre (WWHC) in offering After Hours Crisis Support, which provided free and anonymous counselling services to women across the region. This service was accessible to all women, helping those facing challenging circumstances to receive support as often as needed.

One case involved Drew*, who became homeless after leaving a long-term relationship marked by financial abuse. Drew received risk assessments and regular check-ins from a case manager while awaiting trauma counselling. Over a series of sessions, she began to open up, set goals for financial independence, and accessed further financial counselling support. Drew’s journey

MPHN continues to provide the HealthAccess GP

highlights how this service empowers women to regain

telehealth after-hours service to Griffith, Leeton, Finley,

control over their lives and rebuild stability.

Berrigan, Deniliquin, and surrounding shires, increasing access to essential healthcare across the Murrumbidgee region. The service was used 916 times in the 2023-24 year.

Alongside efforts to promote the service, MPHN trialled a successful initiative where HealthAccess supported overflow patients from the WGPAHS. Patients who were 2023-24 Annual Report

MPHN remains committed to enhancing the health and wellbeing of the Murrumbidgee community through these essential after-hours services, ensuring that residents have the support they need when they require care. * Name changed.

43

While traditionally our focus has been on supporting general practitioners, the past 12 months have seen MPHN support allied health, commissioned service providers, aged care and pharmacy.

Toni Preuss, Senior Manager Integration

supporting health professionals

In this section Helping implement primary healthcare reform locally Supporting general practice Vaccinations and seasonal planning Healthpathways: a key tool for improving patient care Healthy digital connections Inaugural forum for commissioned service providers Fostering allies in health Recognising excellence in primary healthcare

Helping implement primary healthcare reform locally The Commonwealth Government’s Strengthening Medicare initiative has required various levels of support to the region’s primary healthcare providers to help local implementation.

In addition to the day-to-day support provided to the region’s 93 general practices, MPHN’s Primary Care Engagement team have been supporting the implementation of initiatives such as MyMedicare, increased bulk-billing incentives and the Strengthening Medicare GP Grants Program.

Current Senior Manager for Primary Care Engagement Alison Jansen said while the reform initiatives require some intensive support at the practice level, the aim is to help improve the health outcomes for people living across the Murrumbidgee.

“As a Primary Health Network we understand the pressures across the primary care system and want to acknowledge the great work our primary healthcare providers have been doing and continue to do so,” Ms

Chioma Ikeh, Practice Manager at Tumbarumba Medical Practice

Jansen said.

requirements, and infection control. Practice Manager

“While implementation of MyMedicare continues across

grant funding meant they were able to address the most

the region, I am pleased the team has supported 82 of our general practices to register for the platform, which

Chioma Ikeh said the wide scope of areas to invest the pressing areas for their practice.

represents 90 percent of the region’s practices.

“With our grant funding we purchased an AED

“There have been challenges with this implementation

fridge, installed a new server and air conditioning units

nationally, but our established relationships with general practices has made the local rollout a little smoother with MPHN staff providing direct liaison and support, which I know has been greatly appreciated by our practices.”

The Strengthening Medicare GP Grants initiative was finalised this financial year, and a further 18 general practices shared in $460,000 in grant funding to invest in innovation, training, equipment, or minor capital works to enhancing digital health capability, upgrade infection prevention and control arrangements, or maintain or

defibrillator, arranged upgrades for our vaccination with HEPA filters, provided CPR training to all staff and purchased some other office and IT equipment,” Ms Ikeh said.

“Thanks to the grant funding the overall performance and running of our practice has improved, and staff and patients alike are

achieve accreditation.

now enjoying a safer and more

Tumbarumba Medical Practice received a $25,000 grant

efficient practice.”

under the program to undertake a range of activities to support digital health capability, accreditation 46

Chioma Ikeh 2023-24 Annual Report

Key data •

GP Workforce Planning and Prioritisation (WPP) •

Consultation of 62 healthcare professionals and 191 community members

•

1,794 practice support interactions

•

43 Registrars trained in the Murrumbidgee

•

Three University of Wollongong medical students completed placements in Griffith and Leeton

•

520 people attended 34 CPD events

Opening of the Oaklands Medical Centre

Supporting general practice For more than 30 years, MPHN has been providing valuable support to more than 90 general practices across the region in the areas of quality improvement, recruitment and training students, practice establishment and accreditation, and Continuing Professional Development (CPD) opportunities.

While general practice across the country continues to be

consultations,” said MPHN’s Workforce Planning and

impacted by workforce challenges, MPHN’s Primary Care

Prioritisation Manager Jeanette Lautier.

Engagement team helps to ‘lighten the load’ on practice staff and clinicians where they can.

Initial set up and recruitment activities for three new services in the region – Mulwala Medicare Centre and Skin

MPHN’s current Senior Manager Primary Care

Clinic, Quantum Medical Centre in Barham, and Oaklands

Engagement Alison Jansen said the team’s focus for the

Medical Centre – has also been provided by the team.

2023-24 financial year has been to provide practical supports tailored to meet the needs of the general practice.

“The team has provided almost 1,800 occasions of practice support, and the support can vary between practices,” Ms Jansen said.

Equally important is aligning support to general practice with national and state strategies and the priority health needs of the region.

“Given the Murrumbidgee region’s lower cervical screening rates, the team worked with general practice to integrate with the National Cancer Screening Register,

“Some practices require support in recruiting a general

in which the number of practices registered is increasing,

practitioner, others are looking to find efficiencies through

and promoting self-collect cervical screening,” Ms Jansen

quality improvement, or maybe it’s support with setting

said.

up a new practice or guidance with accreditation.”

Alignment with national and state health priorities also

Addressing workforce challenges is the focus of the GP

helped shape MPHN’s new CPD Strategy to facilitate

Workforce Planning and Prioritisation program, which

tailored, innovative and multidisciplinary opportunities

provides local advice and analysis on GP workforce need,

for clinicians across the region.

and training capacity and pathways in collaboration with RACGP and ACRRM.

“It seems our targeted approach to provide relevant and well-timed CDP events is being well received with

“The report collated by MPHN for the program team was

a 77 percent attendance rate for combined in-person

informed by feedback from 62 general practitioners,

and virtual sessions, and 83 percent attendance rate for

general practice staff and students, and 191 community

in-person events,” MPHN’s CPD Coordinator Fiona Baylis

members through an online survey and community

said.

2023-24 Annual Report

47

Wagga Wagga Foodbank pop-up

Vaccinations and seasonal planning MPHN continued to play a crucial role in improving access to vaccinations and providing essential immunisation information to the Murrumbidgee community, ensuring locals had the resources and support needed to stay protected throughout the year.

MPHN’s Clinical Programs and Emergency Response

“That’s why we’ve been active in the local media

Manager Peta Anderson conducted face-to-face visits

encouraging the community to stay proactive and up-

with all 93 general practices in Murrumbidgee, checking

to-date with their vaccinations by checking in with their

vaccine storage fridges, ensuring compliance with cold

local GP or healthcare provider. In most cases, if it’s been

chain standards, and providing immunisation resources.

twelve months since your last COVID booster, it’s time to

She also addressed any questions regarding COVID-19

have another.

and immunisation updates, offering clinical support and guidance to practice staff and nurses.

“We’re working hard to increase vaccination rates, particularly among vulnerable populations such as

In addition to her work with general practice, Ms

residents in retirement and aged care homes, and we’re

Anderson worked closely with retirement and aged care

continuing our efforts with educational sessions on

homes, assisting staff in planning vaccination clinics with

COVID-19 in these facilities.”

local GPs and pharmacies and helping to keep resident COVID-19 and flu vaccinations up to date. MPHN also provided regular reports on COVID-19 vaccination rates to the Department of Health and Aged Care.

Ms Anderson said booster uptake in 2023-24 has been lower across Australia and NSW. “There’s definitely a sense of vaccine fatigue in the

During the year, MPHN held a series of free pop-up clinics across the region at a range of events, providing community members with easy access to vaccinations and healthcare information.

Working with local GPs and Pharmacies, MPHN have been able to provide 1,500 COVID-19, influenza, and Japanese encephalitis vaccinations.

community, and people are confused about which booster they need,” Ms Anderson said.

48

2023-24 Annual Report

Winter Strategy •

31 general practices participated in the Winter Strategy program

•

Collectively they supported more than 775 vulnerable patients with chronic disease

Vaccinations •

100% of the region’s general practices supported with cold chain management

•

1,500 vaccinations for COVID-10, influenza and Japanese encephalitis administered at pop-up clinics

The Murrumbidgee General Practice Winter Strategy

Patients involved in the Winter Strategy reported feeling

program (Winter Strategy) was again delivered in

more confident in managing their own health and

collaboration with MPHN and Murrumbidgee Local

developing stronger relationships with practice staff.

Health District (MLHD) as part of the Living Well, Your

Through this extra care in the general practice setting,

Way Initiative.

the goal is to reduce patients’ need to present at hospital

The Murrumbidgee region has the highest rate of

emergency departments.

potentially preventable hospitalisations across NSW

General practices have reported not only improved

for Chronic Obstructive Pulmonary Disease (COPD) and

patient health outcomes but also benefits in workflow.

Congestive Heart Failure (CHF). The Winter Strategy

Practice staff have been provided with quality education

program aims to keep people diagnosed with chronic

and training allowing everyone involved to be working at

illnesses well and in the community, reducing the

the top of their scope.

likelihood of hospital presentations during the winter period.

Director of Collaborative Commissioning Caroline Holtby highlighted the significance of Winter Strategy in

In 2023-24, 31 general practices participated, each

empowering both patients and healthcare providers to

providing proactive primary care interventions to 25 or

take a proactive approach to managing chronic conditions

more vulnerable patients with chronic disease throughout

during the challenging winter months.

the winter. Practices offered patients enrolled in the Winter Strategy triaged appointments, preventative interventions such as immunisations, updated GP Management and Sick Day Action Plans, follow-up spirometry and ECG testing, and additional monitoring through regular check-ins with practice nurses.

Winter Strategy provides general practices with funding and support from MPHN’s Primary Care Engagement and Living Well, Your Way teams. The funding is used to implement quality improvements, identify suitable patients, and guide intervention activities throughout winter.

“Our Winter Strategy program really helps people feel more supported and cared for during winter,” Ms Holtby said.

“We want to make sure patients are supported in managing their health, and we’ve been really pleased with the results. We’re seeing fewer hospital visits and stronger connections develop between patients and their general practices.

“It’s satisfying to see how our combined efforts can make a difference, not just in the health outcomes but in the confidence and peace of mind it gives to both patients and local healthcare providers.”

2023-24 Annual Report

49

HealthPathways: a key tool for improving patient care The Murrumbidgee HealthPathways program continues to strengthen regional healthcare by equipping clinicians with local information, enabling them to make informed decisions with their patients at the point of care.

It’s been a busy year for the Murrumbidgee HealthPathways team, delivering 52 new clinical pages, 12 new request pages, and six new resource pages.

The free online clinical tool helps clinicians efficiently assess and manage medical conditions, as well as guides local referrals and continues to be well utilised by the region’s health clinicians.

HealthPathways Manager Olivia D’Souza said the program continues to grow and evolve in response to the needs of clinicians and the community.

“Usage of the platform continues to increase, and in the 2023-24 financial year we have increased user numbers by 50 percent, and session and page views by more than

MLHD WWBH JMR-HP presentation

“Our lead role in the prostate cancer suite of pathways

60 percent,” Ms D’Souza said.

meant we were working in collaboration with a diverse

“This year we worked closely with various MPHN

bodies, First Nations organisations, Murrumbidgee

teams and programs to ensure that the localised HealthPathways required for emerging needs were developed as a priority. These included various cardiology and respiratory conditions for the Living Well Your Way team, and child related pathways for the Enhancing

working group, including representatives from peak Local Health District , and local urologists to create the pathways.

“Collaboration was also key in reviewing and updating our diabetes pathways to align with MPHN’s work with

Paediatrics in Primary Care program.”

the statewide initiative for diabetes management and

Murrumbidgee HealthPathways also supported statewide

nurse practitioners, high-risk foot clinic, podiatrists, and

projects for prostate cancer and diabetes management.

community healthcare needs. We worked with specialists, diabetic nurse educators.

“As a team we are honoured

“Our collaborations with state, local and regional

to be the NSW lead region for

date resources which have a tangible impact on patient

the prostate cancer suite of HealthPathways, which was

partners, has ensured we’re delivering valuable, up-tocare,” Ms D’Souza said.

Throughout the year, HealthPathways integrated First Nations, and Culturally and Linguistically Diverse

supported with funding from the

resources into relevant pathways; and developed new

Cancer Institute NSW.”

renal services, voluntary assisted dying, and NSW lead

Olivia D’Souza

50

pathways in the areas of intellectual disability, kidney and region pages travel vaccination and travel consultation.

2023-24 Annual Report

Healthy digital connections MPHN offers a variety of digital health support to local primary healthcare providers including general practice, pharmacy, aged care, and allied health, and this year the main focus was on conducting a Digital Health Maturity Assessment.

To gain an understanding of the spectrum of digital health maturity for the region’s healthcare providers, MPHN engaged Semantic Consulting to deliver a Digital Health Maturity Assessment for general practices, aged care homes and allied health organisations.

MPHN’s Digital Health Lead Dr Vimal Pasupathy (PhD) said participation was very high and the outcomes of the assessment will be analysed and shared as an action plan for participating organisations .

“We had 100 percent return rate from aged care homes, 85 percent of general practices, and 25 allied health organisations complete the digital health maturity assessment survey,” Dr Pasupathy said.

“We will use the survey data to provide a tailored approach to digital health change and adoption for those participating individuals and organisations, which will help to increase the region’s digital health maturity level.”

MPHN’s Vimal Pasupathy with Dr Wahba at Henty Medical Centre

For example, the current allergy, medication, medical history and immunisation details in My Health Record

Digital Health Maturity Assessment participant, Dr.

of a new patient are a couple of clicks away for me to be

Nachaat Wahba from Henty Medical Centre said digital

able to provide some continuity of care for my patient,” Dr

health applications make his consultations easier.

Wahba said.

“Having access to digital platforms such as My Health

“Thank you to the MPHN digital health team for keeping

Record, eRequest, ePrescribing and SafeScript assists me

the system alive and always being available when we need

in the right treatment decision-making at the right time.

assistance. I appreciate it.”

How digitally connected are Murrumbidgee health practitioners?

•

Almost all general practices can now receive

•

eRequest (electronic pathology request).

electronic hospital discharge summaries after significant work with Murrumbidgee Local Health District to assist more than 65 general practices.

•

NASH certificate for My Heath Record.

•

•

prescription.

•

information about a patient’s medication history for high-risk medicines.

supported to complete Provider Connect Australia streamline notifications.

2023-24 Annual Report

SafeScript has been implemented across the region enabling prescribers and dispensers with real-time

34 general practices and 25 pharmacies have been registrations this year to help reduce duplication and

Almost all of the region’s general practices and pharmacies are connected to use electronic

Almost all eligible general practices and pharmacies across the region have been upgraded to the SHA-2

70% of eligible general practices are enabled to use

•

42 general practices are registered for LUMOS to provide end-to-end overview of a patient journey.

51

Inaugural forum for commissioned service providers

Innovation moment

In May, MPHN delivered its inaugural Commissioned Provider Forum in Wagga Wagga and received such positive feedback it’s set to become a regular event.

Attended by almost 40 of MPHN’s commissioned service

“These stories also assist MPHN to invest in our

providers, MPHN’s inaugural Provider Forum delivered a

communities to address need, support providers and

program aimed at creating opportunities for networking,

improve collaboration for an improved patient journey

sharing experiences and stories, learning from others, and

and outcomes, and look for opportunities to lead

gaining a greater understanding of the commissioning

innovation and make a positive impact.”

processes.

MPHN’s Acting CEO, Narelle Mills provided the Forum

MPHN’s Senior Manager Commissioning Janelle Dufty

welcome address and noted innovation is one way to

said all the region’s service providers play a significant role

address challenges, and in the rural and regional context,

in partnering with MPHN to improve health outcomes for

partnerships and collaboration are critical.

our communities.

“One area where we can partner together to innovate is

“A provider forum has been something we have wanted

around supporting a sustainable health workforce. It’s

to host for a long time – but, we all know the global

easy to say, we don’t have this clinician or that service, but

pandemic has presented many challenges, including

I know how innovative rural people can be when they look

bringing people together,” Ms Dufty said.

for solutions that leverage what they do have,” Ms Mills

“Over the years, across our communities we know our

said.

commissioned service providers are achieving positive

Feedback from attendees has been positive with one

health outcomes and we see this in the good news stories

saying “the overall day was informative. Great to hear

they share as part of their regular reporting. Sharing

more about PHN teams, functions, roles, planning

these stories is critical to showcasing what we can and are

cycles etcetera.” MPHN is looking forward to making the

achieving locally, and inspiring others working in regional

Provider Forum a regular event on the MPHN calendar.

and rural healthcare.

Attendees at MPHN's inaugural Commissioned Service Provider Forum

52

2023-24 Annual Report

At your fingertips To support the region’s allied health professionals, a dedicated page on MPHN’s website was developed. Included on the page are resources, education and training, local health pathways, and information about various local projects, programs and models of care involving allied health.

We also heard the need for consolidating allied health specific information for our region and have established a new allied health page on our website.

mphn.org.au/alliedhealth

Brad Piffero

Fostering allies in health Allied Health professionals are integral to primary healthcare, and are essential for improving access, outcomes, integration, safety, and quality across the health system.

A new Framework developed to strengthen engagement

healthcare to improve access, outcomes, integration,

between the Primary Health Networks (PHN) and the

safety, quality and cost-efficiency across the health

allied health sector was launched in 2023 by the National

system and to embed effective allied health engagement

PHN Cooperative. The National PHN Allied Health in

in MPHN’s practices.”

Primary Care Engagement Framework (the Framework) will serve as a roadmap for MPHN to increase its collaboration and support with the region’s allied health practitioners.

MPHN’s Allied Health Engagement Lead, Brad Piffero said there are two aspects for implementation of the Framework locally across the Murrumbidgee – allied health support and commissioning of multidisciplinary teams.

“My role is primarily focussed on the allied health support aspect of the framework which involves connecting with Murrumbidgee allied health providers to strengthen relationships and encourage collaboration among allied health, general practice, and aged care,” Mr Piffero said.

“To achieve this we have been working with local allied health clinicians to help identify gaps, challenges and opportunities and develop a localised approach for MPHN’s Allied Health Strategy. Part of this is to establish an Allied Health Reference Group.

“The ultimate goal of this work is to further enhance and integrate allied health professions as part of primary

2023-24 Annual Report

In May 2024 MPHN conducted a series of focus groups with allied health clinicians to understand these gaps, challenges and opportunities.

“Feedback from our focus group sessions included workforce challenges with attracting and retaining allied health professionals, opportunities to build professional relationships between general practice and allied health, the need for improved digital health integration, business support and networking, and allied health specific and relevant CPD events,” Mr Piffero explained.

“We also heard the need for consolidating allied health specific information for our region and have established a new allied health page on our website.

“The Allied Health Advisory Group, which will provide valuable advice and recommendations to help guide MPHN’s decision making, is in the process of being established with members from various allied health professions working across the Murrumbidgee.”

MPHN’s Allied Health Strategy will be completed late in 2024.

53

Recognising excellence in primary healthcare In a celebration of excellence and dedication, the 2023 Murrumbidgee Primary Healthcare Awards took place in Wagga Wagga on Friday 10 November, honouring outstanding contributions in the field of primary healthcare.

The awards ceremony showcased the extraordinary

“The grandmother was nearly in tears because of what

achievements of local healthcare heroes from across

she called the transformation of her grandson. She told

the region, with the winners right across the region

us, ‘He used to be that child who was rummaging in the

implementing activities supporting young people, older

cupboards looking for packaged foods, now he’s looking

people, and people impacted by bushfire.

for fruit and veggies, trying new foods, and sharing his

MPHN’s firsthealth Board Chair Dr Jodi Culbert said opportunities to recognise local achievements in primary healthcare were critical.

“The achievements and positive health outcomes from each of our finalists is inspiring, and on behalf of the Board and MPHN Senior Leadership team, thank you for all you do to support health and wellbeing in your communities,” Dr Culbert said.

Nicole Jenkins accepted the Innovation award for the Integrating Generations of the Deniliquin Community activity in Deniliquin said “it’s wonderful that teenagers I work with are really taking this on board and coming in each week bringing these young children together with older adults; there’s nothing more rewarding”.

The initiative brought together high school students, preschoolers, and older adults, fostering empathy and leadership skills among the students while promoting understanding between the generations.

The winner of the Promoting Healthy Living award was Making Friends With Food by The Root Cause where 1,668 children from 11 primary schools across the Murrumbidgee participated in a 12-month program to foster positive and lifelong relationships with food.

Accepting the award, Belinda Smith shared a touching story about a grandmother who reached out after her

love of fresh food with his friends at school.’ Without the MPHN, we wouldn’t have been able to do that.”

Community Grant of the Year award went to the Community Foundation for Tumut Region for its Fireshed Fridays and High Teas events that fostered community connections and resilience across the Snowy Valleys and provided mental health support and educational sessions after the devastating 2019/2020 bushfires. Accepting the award Louise Halsey said “we’ve been to 25 firesheds right across the area; we arrive with a sit-down dinner, tablecloths, and we use juvenile growth eucalyptus for decorations as a symbol of regrowth. If we have made a difference to one of those firemen, our job’s done.”

The Outstanding Contribution to Leadership in Primary Healthcare award went to Dr Rachel Christmas in acknowledgement for her remarkable leadership in rural healthcare and pivotal role in strengthening of primary care provision in Temora and the surrounding region.

On accepting the award Dr Christmas said “I see lots of communities around the district where so many people are doing amazing things. I’m really appreciative of this [award], and I’m quite overwhelmed by it because it was not expected. Thank you to all the people here who contribute so beautifully to their communities, believe in what they do, and have optimism for a wonderful future.”

grandson had participated in the program.

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2023-24 Annual Report

“The achievements and positive health outcomes from each of our finalists is inspiring, and on behalf of the Board and MPHN Senior Leadership team, thank you for all you do to support health and wellbeing in your communities.”

Dr Jodi Culbert

Winners of the 2023 Murrumbidgee Primary Healthcare Awards

Award winners and finalists Outstanding Contribution to Leadership in Primary Healthcare Winner: Dr Rachel Christmas Highly commended: Palliative Care Outcome Collaborative Finalist: Evan Feather Innovation Winner: Intergenerational Activity: Integrating Generations of the Deniliquin Community Finalist: Alternative Workforce Program

Promoting Healthy Living Winner: The Children’s Health Program Finalist: EMPOWER Finalist: Frontline Emergency Distress and Trauma Counselling Murrumbidgee Grant of the Year Winner: Fireshed Fridays and High Teas Highly commended: Blokes Night In Finalist: Women’s Wellbeing Event – Breast and Cervical Screening

Finalist: The Old Servo, Henty 2023-24 Annual Report

55

System integration work is critical to ensure people can move through the health system seamlessly, and the work we have progressed in this area over the last 12 months demonstrates innovative ways in how we are gradually making meaningful and sustainable system changes.

Narelle Mills, Executive Integration and Partnerships

one health system In this section Living Well, Your Way Improving access to diabetes care Enhancing paediatric care for a brighter future Medicare Mental Health Centres for Wagga Wagga and Young System transformation and integration in the one precinct

Living Well, Your Way The Living Well, Your Way initiative is transforming how care is delivered for people with chronic conditions in the Murrumbidgee region, focusing on innovative, patient-centred solutions that improve access to affordable and equitable healthcare.

Living Well, Your Way (LWYW) is a collaborative effort

“By combining our strengths and resources, we’re not just

between MPHN and Murrumbidgee Local Health District

improving individual health outcomes, we’re fostering a

(MLHD), funded by NSW Health. It aims to improve care

supportive and better-connected community.”

for people living with Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF).

By working closely with local healthcare professionals, LWYW addresses challenges such as long travel distances and high healthcare costs, with a particular focus on reducing preventable hospitalisations.

The Outreach Heart Failure Diagnostic Clinic is another important component, providing at-risk rural patients with affordable access to diagnostic services. The clinic is a public-private partnership involving MPHN, MLHD, Roy Cardiology, St Vincent’s Network, and Aboriginal Medical Services, which aims to improve heart

The initiative includes a range of programs, such as

failure management and reduce preventable hospital

pharmacy screening, outreach diagnostics, expanded

admissions.

primary care services, and culturally appropriate rehabilitation programs that give patients confidence to manage their health from home. A key aspect of LWYW is the Pharmacy Screening Program, which identifies at-risk patients and refers them to GPs for further assessment, playing a critical role in reducing hospitalisations.

Developed in collaboration with GPs and pharmacists, this pilot program uses tools such as micro-spirometry to detect early signs of disease, aiming to improve diagnosis

Associate Professor Andrew Roy, of Roy Cardiology / St Vincent’s Network – Sydney, said he was pleased with the clinic’s progress.

“The Outreach Heart Failure Diagnostic Clinic showcases the transformative potential of collaborative healthcare models,” Associate Professor Roy said.

“By bridging gaps in access and expertise, bringing

and lower healthcare costs.

specialists together with the communities that need

Director Collaborative Commissioning Caroline Holtby

empowering patients to take control of their health

said it was satisfying to see the impact Living Well, Your Way was having in people’s lives.

support, we are not only diagnosing conditions but also journey.”

“Working together with local health professionals and community members is essential in helping people with chronic conditions live well,” Ms Holtby said.

Outreach Heart Failure Diagnostic Clinics in Hay

58

2023-24 Annual Report

As part of the initiative, two public outpatient clinics, one

the benefits of rehabilitation and better manage their

for respiratory care and the other for heart failure, were

conditions.

introduced at the Ambulatory Care Hub in Wagga Wagga.

These clinics aim to prevent hospital readmissions and support home-based management of complex respiratory and cardiac conditions. Led by Dr Adriaan Venter, the Respiratory Outpatient Clinic offers on-site lung function testing to help with diagnosis and treatment. The Public Heart Failure Clinic, in partnership with Riverina Cardiology, delivers comprehensive care, including diagnostics, pharmaceutical education, and physiotherapy assessments.

LWYW funding has also enabled the expansion of Wagga Wagga Base Hospital’s Rapid Access Clinic, offering evening and weekend services to reduce emergency department pressures. The initiative continues to engage with general practitioners to promote the clinic’s services.

Finally, the CareMonitor mobile app allows patients to track their health metrics and receive instant management advice. Since 2023, over 150 patients and 19 general practices in Murrumbidgee have been using this

The program also includes a culturally safe rehabilitation pilot for Aboriginal and Torres Strait Islander communities, developed in partnership with Griffith Aboriginal Medical Service and MLHD. Known as ‘Murundhu I Live, I Breathe,’ the pilot is set to expand following its initial success.

tool to better manage their chronic conditions.

The Living Well, Your Way initiative is not only improving access to essential healthcare services but also fostering a collaborative, community-centred approach to managing chronic conditions. Through innovative programs, partnerships, and culturally appropriate care,

In addition, LWYW partnered with the Lung Foundation to train local physiotherapists and exercise physiologists to offer Lungs in Action classes in the Murrumbidgee. Four

LWYW is helping Murrumbidgee residents take control of their health, ultimately reducing hospitalisations and enhancing their quality of life.

classes have already started in Wagga Wagga, Tumut, and Harden, with six more professionals set to be accredited in 2024. These classes aim to help patients maintain

4,792

1,128

165

901

Patient encounters

Patients targeted

Patients

Patients enrolled

through Medical

screened in 11

in the Winter

Director prompt in

pharmacies

Strategy in 34

with the pathway

General Practices

General Practice

78

18

Patients signed up to

Patients enrolled in

use Care Monitor

two Commissioned Rehab Programs

457

1,509

42

4

Clinicians and staff

PREM & PROM

General Practices

General Practices using

trained

surveys conducted

signed up for

the HOPE platform

Lumos

2023-24 Annual Report

59

The St Vincent’s Health Network Sydney DREAM team working in collaboration with the Gundagai Medical Centre

Improving access to diabetes care MPHN continues to strengthen partnerships with key organisations to improve access to diabetes care for residents across the region.

In collaboration with St Vincent’s Health Network Sydney

“This initiative also affords our region’s general

and Murrumbidgee Local Health District, MPHN has

practitioners and practice nurses the chance to glean

supported the implementation of the Diabetes Regional

insights from some of Australia’s leading diabetes

Education, Access, and Management (DREAM) Initiative.

specialists.”

This initiative, designed specifically for rural and regional communities, is addressing gaps in specialist diabetes care, bringing much-needed services closer to home.

The outreach clinics provided patients with direct access to specialist diabetes services, reducing the need for long-distance travel to metropolitan centres.

The DREAM Initiative, spearheaded by St Vincent’s

Additionally, local general practitioners, practice nurses,

Health Network Sydney, has been co-designed with local

and allied health professionals were able to participate

healthcare providers to ensure the solutions meet the

in professional development workshops, learning about

specific needs of communities in the Murrumbidgee

the latest advancements in diabetes care and engaging in

region. In early 2024, the initiative launched a series of

collaborative patient care discussions.

outreach clinics and professional development sessions for healthcare professionals in rural areas, including Gundagai and Tumut.

MPHN’s Senior Manager Integration Toni Preuss highlighted the importance of these collaborations in tackling diabetes.

“Compared with all NSW Primary Health Networks, our region has the highest prevalence of diabetes, affecting more than 10 percent of our total adult population”’ Ms Preuss said.

“Offering patients access to local specialist services, which complement and work with our existing specialists and primary care providers, is pivotal to enhancing health outcomes.

60

St Vincent’s Diabetes Clinical Nurse Consultant Gael Holters, who leads the project, said she enjoyed spending time in the Murrumbidgee.

“Being in the Murrumbidgee is helping us better understand the unique challenges and needs of rural communities in managing diabetes,” Ms Holters said.

“Through this initiative, we’ll be able to tailor our approach to best fit the circumstances in the region, ensuring we’re not just implementing standard protocols, but crafting solutions that reflect the realities of rural life.

“We’re grateful for the support of Murrumbidgee Primary Health Network in facilitating the involvement of local practices. Their collaboration has been invaluable in extending our reach and impact.”

2023-24 Annual Report

Enhancing paediatric care for a brighter future The Enhanced Paediatrics in Primary Care (EPiPC) program is making a significant difference in the lives of young children across the Murrumbidgee region by providing early intervention for behavioural and developmental issues through a coordinated, community-based approach.

This year EPiPC continued to aid children and their

Recent success stories include instances where children

families across the Deniliquin, Gundagai, Hay, Wagga

were supported without needing in-person paediatric

Wagga, and Leeton communities. GPs continued to

appointments. Through email consultations, GPs received

enhance their professional development, conduct

community paediatrician advice, enabling timely support

screenings, and provide extended appointments for

and reducing wait times. For example, a 3-year-old child

children with behavioural and developmental concerns.

with mild developmental difficulties and a 5-year-old with

The WARATAH for Kids service ran monthly or bi-

sensory behaviours were both able to access appropriate

monthly clinics to ensure families received the support

services such as allied health and child and family health

they needed. The Enhancing Paediatrics in Primary Care

nursing without requiring specialist paediatric care. This

Workshop in September 2023 was also successful, with

not only streamlined referrals but also helped to ease the

participants reporting increased confidence in managing

burden on local paediatric services.

paediatric care.

The EPiPC program focuses on early detection and

MPHN’s Contracts Manager Christina Eastall said EPiPC

management of developmental concerns in children

was continuing to give young children in the community

aged 0-7, ensuring timely support for vulnerable

the best chance to thrive by identifying behavioural and

families. Through partnerships with GPs, allied health

developmental issues early.

professionals, and a community paediatrician, the

“The collaboration between our GPs, paediatricians, and allied health teams ensures families can access the right care when they need it,” Ms Eastall said.

“This program is helping communities to build stronger foundations for the future health of their children, and we’re really pleased with the positive impact it’s having across the Murrumbidgee.”

program takes an integrated approach to paediatric care. Special interest GPs receive guidance from the paediatrician, conducting regular screenings and extended appointments to address issues early. The program also includes the WARATAH for Kids service, which includes occupational therapists and speech pathologists providing assessments and case conferences to ensure coordinated care for each child.

2023 Enhancing Paediatrics in Primary Care Workshop

2023-24 Annual Report

61

Medicare Mental Health Centres for Wagga Wagga and Young As part of the New South Wales (NSW) Bilateral Schedule on Mental Health and Suicide Prevention, a partnership between the Commonwealth and NSW governments, two new adult Medicare Mental Health Centres were established in Wagga Wagga and Young.

Designed to offer a welcoming, low-stigma entry point

“Each consortium organisation is working together

for people experiencing distress or crisis, the Medicare

to deliver a service that considers minimising service

Mental Health Centres in Wagga Wagga and Young

duplication and continuity of care for the client,” Mr

provide a new way for adult Australians to access free,

Phillips said.

quality mental health care as well as access to support for people experiencing substance use issues.

“The consortium approach will provide opportunities for shared workforce allocation, and we have already initiated

While the services began in June 2024, MPHN has worked

an early career clinician program and network which

in partnership with Murrumbidgee Local Health District

includes a student placement program. This promotes a

(MLHD) since mid-2023 to bring the centres to fruition.

‘grow your own’ approach to supporting local graduate

MPHN’s Senior Manager Commissioning, Janelle Dufty

and intern positions to develop their experience and skills

said key to the establishment of the two centres was

within the Medicare Mental Health Centre model.”

working together to understand the local needs.

Medicare Mental Health Centres provide a safe and

“The partnership with MLHD has been critical to the

welcoming place for adults to access mental health

service co-design to ensure the Medicare Mental Health

information, services and supports delivered by

Centres integrate with existing services and minimise

multidisciplinary care teams over extended hours,

service duplication,” Ms Dufty said.

without needing a prior appointment or paying a fee.

Grand Pacific Health was appointed lead service provider for both centres as part of a consortium arrangement with Directions Health, Mission Australia and Riverina Medical & Dental Aboriginal Corporation. Grand Pacific Health

Services include short to medium term care for adults with moderate to severe mental health needs and immediate support and follow up for people presenting in crisis or distress.

CEO Adam Phillips said the consortium is committed to

Bilateral activities aim to support improved mental

integrating with existing services in the region to offer

health and suicide prevention outcomes for people in

holistic care and identifying new approaches to workforce

NSW, through collaborative efforts to address gaps in the

challenges.

mental health and suicide prevention service system.

Minister McBride visits the new Medicare Mental Health Centre site in Wagga Wagga

In June 2024 MPHN was pleased to host Assistant Minister for Mental Health and Suicide Prevention, the Honourable Emma McBride MP, for a site tour at the Wagga Wagga Medicare Mental Health Centre. The new centre will be ready in late 2024, and services are being provided in the meantime at Mission Australia, one of the Consortium members delivering the service. During her visit, Minister McBride met with Medicare Mental Health Centre staff and said she was “pleased to see work progressing so quickly on the Wagga Wagga Medicare Mental Health Centre.”

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2023-24 Annual Report

In early July 2024, the Murrumbidgee Health and Knowledge Precinct held its first Regional Health Innovation Showcase. More than 130 attendees enjoyed the opportunity to network and take part in meaningful discussions and explore the innovative digital and printed posters showcasing 45 innovative programs currently taking place in our region. The following MPHN led projects were part of this poster showcase: •

CareMonitor

•

Living Well, Your Way

•

MPHN Research Strategy

•

MPHN Telehealth

•

Murundhu I Live I Breathe, Designing a rural digital mental health education hub (with Three Rivers).

System transformation and integration in the one precinct

Innovation moment

The Murrumbidgee Health and Knowledge Precinct (the Precinct) presents an innovative approach to addressing rural healthcare challenges in the Murrumbidgee region. MPHN is a proud partner of this initiative, which aims to support the development of healthcare solutions for our communities.

MPHN has continued its partnership with the

“The framework will be used by the Health and

Murrumbidgee Health and Knowledge Precinct, and

Knowledge Precinct and its partners to support region-

this year, with the Precincts One System Precincts One

wide planning and response, leading to the development

System Integration Working Group, commissioned the

of models of care based on local need and optimising the

development of a regional health planning framework.

use of resources where possible”.

MPHN’s Executive Integration and Partnerships and

Development of the framework is currently progressing,

MPHN representative on the Precinct Board and chair of

with the framework to be delivered in early 2025.

the working group, Narelle Mills said a regional planning

The Precincts One System Integration Working group

framework will provide a structured and consistent

members include:

approach to health planning and considers population

•

MPHN

•

Murrumbidgee Local Health District (MLHD)

•

Regional NSW

•

Business NSW

holds. Through enhancing regional collaboration we’re

•

NSW Health Regional Health Division

aiming to help ensure that everyone, no matter where

•

NSW Rural Doctors Network

health needs at the local level.

“The Regional Planning Framework will allow us to both respond to current challenges and build a resilient healthcare system that can adapt to whatever the future

they live, has access to the quality healthcare they deserve,” Ms Mills said.

2023-24 Annual Report

63

Engagement with our people continues to be high, and is a result of all team members truly living our values.

Kristy Hawkins, Senior Manager Corporate Services

living our values

In this section A great place to work Treasurer’s report Grant recipients Commissioned Service Providers

A great place to work MPHN’s values—work together, be honest, value everyone, aim to inspire, and learn from others—are key to creating a great workplace. These principles foster collaboration, integrity, and respect, making MPHN a place where everyone feels valued and motivated to grow.

So much of MPHN’s work could not be achieved without

This year, we’ve had the pleasure of welcoming 19 new

its employees - in fact, Our People is an enabler of our

faces to the MPHN family, bringing fresh energy and ideas

Strategic Plan - and while we are dilligently working away,

to our team. These new staff members contribute diverse

it is important to take time to celebrate achievements and

skills and perspectives, marking an exciting chapter for

learn new things.

MPHN as we continue to grow and make a positive impact

Human Resources Manager Ericka Burgun said staff are the heart of MPHN. “Their dedication, passion, and commitment to our mission are what drive our success,” Ms Burgun said.

“We value each team member and recognise it’s their collective effort that makes MPHN a place where we can all make a meaningful difference to the health and

together.

On 29 May 2024, during National Reconciliation Week, we held our annual Big Day In, bringing together all MPHN employees in Wagga Wagga to experience, learn, and share. MPHN’s Mental Health Clinical Lead, Edwina Scerri, presented a session on workplace wellbeing. Staff engaged in an activity to provide feedback on the Pulse Survey results, followed by each department showcasing

wellbeing of the Murrumbidgee community.”

one of MPHN’s organisational values through a skit or

In fact, 95 percent of staff say they would recommend

and feedback indicated that staff appreciated the effort

MPHN as a great place to work, according to a pulse survey conducted in April 2024. The survey also found staff were supportive of MPHN’s CEO transition, with many expressing gratitude to Acting CEO Narelle Mills for leading the organisation through this change.

The long-term commitment of staff, with some being with the organisation for over 10 years, is a testament to our strong values and positive workplace culture. This year we celebrated the 10-year anniversaries of Mental Health, Alcohol and Other Drugs Manager Maja Asmus, and Senior Manager Commissioning Janelle Dufty.

“I feel like the organisation is a very welcoming place, it’s my second home really,” Ms Dufty said.

“I feel like everyone’s very respectful of each other; it’s a supportive environment. I always feel proud to work here.”

performance. The values activity was highly entertaining, their colleagues put into the presentations. The day concluded with a visit to ErinEarth, where the team was guided by Indigenous Elders and knowledge experts through the garden, learning how to make damper and johnny cakes. It was a beautiful sunny day, and the team enjoyed the mix of activities.

Marking these cultural days of significance is a key action from MPHN’s Innovate Reconciliation Action Plan.

The working group, comprised of MPHN employees, guides the organisation on how to recognise these days in culturally appropriate ways, while also providing an opportunity for staff to learn, appreciate and understand First Nations culture.

MPHN’s commitment to its core values not only fosters a supportive and inclusive workplace but also drives our success and growth. By celebrating milestones, valuing

MPHN’s ‘wellbeing calendar’ is filled with activities

long-term dedication, and actively engaging in wellbeing

that bring our team together and support each other’s

initiatives, we’re ensuring that every team member feels

wellbeing. From celebrating Harmony Day and taking

valued and inspired. Our recent activities and positive

part in Reconciliation Week and R U OK Day, to enjoying a

survey feedback affirm that we’re on the right track. As

whole month of ‘Take Your Dog to Work Day,’ these events

we continue to welcome new members and embrace new

create opportunities for connection, inclusivity, and

opportunities, MPHN remains dedicated to our vision of

meaningful conversations. They reflect our commitment

fostering well people and resilient communities across

to nurturing a warm, supportive workplace where

the Murrumbidgee.

everyone feels valued and cared for.

Backwards Cap Day (Dec 2023), Ugly Shirt Day (Dec 2023), Wagga Mardi Gras (Mar 2024) ,Christmas party (Dec 2023), RedFeb (Feb 2024), Big Day In (May 2024), Erin Earth (May 2024), Big Day In (Nov 2023), Primary Care Nurses Day (Feb 2024), Erin Earth (May 2024)

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2023-24 Annual Report

Treasurer’s Report I am pleased to present the highlights of the 2023-24

Please refer to the graphics on the next page which show

financial report for firsthealth Limited.

the sources and applications of the funding received and

The company’s major activity remains the conduct of the Murrumbidgee Primary Health Network (MPHN) under

effectively managed by the company in deliverables to funders.

contract with the Australian Government Department of

In 2023-24 the company treated operational funding

Health and Aged Care. The company also received funding

(funds not contractually obligated for direct service

from other sources under separate contracts, aimed at

delivery) from funders other than the Australian

improving access and quality of primary healthcare across

Government Department of Health and Aged Care

the Murrumbidgee.

as retained earnings. The amount being $463,000.

The company once again realised growth in funding.

The company will utilise 90 percent of these funds to contribute to the operational costs of firsthealth Limited in 2024-25. In 2023-24 the company made a profit of $503,820.

Full financial statements are available on the company’s

“Revenue from funders increased by nine percent overall from the previous year to $38 million.

These funds have been applied directly toward the provision of health services throughout the Murrumbidgee in accordance with relevan funding agreements”

website. I particularly draw your attention to Note 1 Basis of Preparation, Note 2 Summary of Material Accounting Policies, and Note 3 Critical Accounting Estimates and Judgements.

Paul Gianniotis

Paul Gianniotis As at 30 June 2024, the company held an additional $8 million in unspent funding which will be utilised for health service provision in 2024-25. It is important to note that a significant proportion of this amount has already been committed in contracts with service providers to fund the delivery of health services. Firsthealth Limited continues to implement plans to utilise these funds in an agile and community-led manner.

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2023-24 Annual Report

1% CLIENT FEES & SERVICES

14% OTHER SOURCES

1% BOARD & COMMITTEE COSTS

3% INTEREST EARNED

2% SERVICE FEES

5% OTHER EXPENSES

2% GRANTS

0% OTHER INCOME

2% GP PAYMENTS 1% COMMUNICATIONS

18% EMPLOYMENT COSTS 70% CONTRACTORS 82% AUSTRALIAN GOVERNMENT DEPARTMENT OF HEALTH AND AGED CARE

REVENUE

EXPENSES

Revenue SOURCE

2023-2024

2022-2023

% CHANGE

AUSTRALIAN GOVERNMENT DEPARTMENT OF HEALTH AND AGED CARE

$32,193,339

$31,824,873

1%

FUNDING (OTHER SOURCES)

$5,307,643

$2,504,412

112%

CLIENT FEES AND SERVICES

$453,360

$422,227

7%

INTEREST EARNED

$1,238,449

$717,973

70%

OTHER INCOME

$14,242

$26,160

-46%

$39,207,032

$35,505,646

10%

2023-2024

2022-2023

% CHANGE

CONTRACTORS

$27,074,399

$24,330,308

11%

EMPLOYMENT COSTS

$6,867,932

$5,484,744

25%

BOARD & COMMITTEE COSTS

$198,180

$288,612

-31%

GP PAYMENTS

$672,242

$567,989

18%

GRANTS

$782,038

$2,210,618

-65%

COMMUNICATIONS

$225,263

$300,623

-25%

SERVICE FEES

$850,228

$574,419

48%

OTHER EXPENSES

$2,032,930

$1,678,613

21%

TOTAL

$38,703,212

$35,436,926

9%

$503,820

$68,720

TOTAL

Expenses SOURCE

PROFIT (OR LOSS)

2023-24 Annual Report

69

Grants recipients The following organisations were funded by MPHN to deliver grant activity in the 20232024 financial year.

Active Farmers Beckom Public School P & C Boorowa Street Practice Central Wagga Medical and Skin Clinic Coleambally Medical Centre Country Med Group Courabyra Public Hall

Country Womens Association of NSW (Galore, Ganmain)

Moulamein Art & Craft Council Incorporated

Generocity Church

Moulamein Community Development Inc.

Gundagai Medical Centre Harden Murrumburrah Regional Development Henty Early Childhood Association Inc.

Culcairn Medical Practice

Henty Local Health Advisory Committee

Darlington Point Medical Centre

Hillston Ex-Servicemen’s Club

Deniliquin Business Chamber

Jindera Medical Clinic

Deniliquin Clinic

Jerilderie Sports Club

Deniliquin Junior Giants Basketball Association

Jingellic Rural Bushfire Brigade

Deniliquin Local Health Advisory Committee Deniliquin Mental Health Awareness Group Deniliquin Pony Club Dr Taghrid Samuel

Junee Medical Centre Lions Club of Henty Lockhart Medical Practice Lower Lachlan Community Services Mathoura Public School P & C Association

Murrumbidgee Men’s Group Rotaract Club of Wagga Wagga Sarkon Medical Centre Tarcutta Valley Landcare Group Tatton Medical Centre The Middle, Adelong Tocumwal’s Little Explorers Urana Medical Centre VeCare Health Walla Walla Victoria Street Surgery Whispering Wellness Yamandhy Narang Young District Medical Centre Zac’s Place Incorporated

Commissioned service providers The following organisations were funded by MPHN to deliver a service in the 2023-2024 financial year.

Ardlethan Pharmacy

Blooms the Chemist Sturt Mall

Coolamon Regional Medical Centre

Ariah Park Pharmacy

Boorowa Hospital Medical Centre

Coolamon Shire Council

Assem Swaid Medical

Boorowa Pharmacy

Corowa Medical Centre

Australian Red Cross Society

C7EVEN Communications

Culcairn Medical Practice

Back on Track Physiotherapy

Calvary Health Care Riverina

Cypress View Lodge

Barham Pharmacy

Capital Chemist Narrandera

Deniliquin Clinic

Beacon Strategies

CBT Institute

Diabetes Australia

Berrigan and District Aged Care Association

Centacare South West NSW

Directions Health Services

Consultmed

Dr Duncans Rooms

Cooinda Court Aged Care

Dr. Marietjie Van der Merwe

Blamey Street Surgery Blooms the Chemist Griffith

70

2023-24 Annual Report

Drive Thru Pharmacy Griffith East Griffith Pharmacy Echuca Moama Family Medical Practice Emily Gardens Foodbank NSW Forest Hill Pharmacy Ganmain Show Society Inc Gidget Foundation Australia Glenrock Country Practice (Glenfield, Lake Albert, The Rock) Grand Pacific Health Griffith Aboriginal Medical Service Aboriginal Corporation Griffith Meals on Wheels Inc Griffith Medical Centre Hamblins Amcal Pharmacy Hammond Health HammondCare Harden Grange Haydays Retirement Hostel Hay Medical Centre Healthy Communities Foundation Australia Hillston Medical Centre Human Capital Alliance Insight Consulting J Alster & M Alster JAPPS Pharmacy John Dodd Pharmacy Junee Capital Chemist Junee Community Centre Junee Medical Centre Kooringal Medical Centre Kooringal Pharmacy

Leeton Multicultural Support Group Inc Lions Club of Narrandera Incorporated Lockhart Medical Practice Marathon Health Mercy Place Mount Saint Joseph’s Young NSW

Swan Hill District Health Terry White Chemmart Tolland The Bush Chemist Batlow The Bush Chemist Cootamundra The Bush Chemist Leeton The Bush Chemist Tumut

Moama Health Clinic

The Bush Chemist Wagga

Moama Village Pharmacy

The Root Cause

Morgan Street Healthcare Clinic

TMC Medical Group

Moulamein Retirement Village

Trinity Medical Centre

Moving Tails

Trail Street Medical Centre

Multicultural Council of Wagga Wagga

Tumbarumba Medical Practice

Murray Haven Homes Murrumbidgee Local Health District Murrumbidgee Medical & Primary Care Centre Narrandera Medical Centre Navorina Nursing Home Nova Health Co Painchek Ltd Pat Zirilli Amcal Chemist Peter Street Medical Centre Phil Davies Amcal Pharmacy Playgroup NSW

Tumut Family Medical Centre Uniting (NSW,ACT) Uralba Hostel VeCare Health Holbrook VeCare Health Walla Walla Viney Morgan Wagga Wagga City Council Wagga Wagga Medical Centre Wagga Womens Health Centre Wellways Australia Western Sydney Local Health District Young District Medical Centre

Priceline Pharmacy Swan Hill Queensland University of Technology Rao Medical Centre Relationships Australia Canberra and Region Respect Woodhaven at Lockhart Riverina Family Medicine Riverina Medical & Dental Aboriginal Corporation

Lachlan Lodge

Rotary Club of Coolamon Inc.

Lake Albert Pharmacy

Roth’s Corner Medical Centre

Lakeside Medical Centre

Royal Far West

Leeton Amcal Pharmacy

Soul Pattinson Chemist Deniliquin

Leeton and District Local Aboriginal Land Council

Southcity Pharmacy

2023-24 Annual Report

Sunflower House

Michael O’Reilly Pharmacy

Kure Medical - West Wyalong

Leeton Medical Practice

Stride Mental Health Limited

St George Family Medical Centre

71

mphn.org.au Tel 02 6923 3100 Fax 02 6931 7822 1/185 Morgan Street Wagga Wagga NSW 2650