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Welcome to the first issue of the Northern NSW Integrated Care Newsletter for 2017, regular subscribers will notice the new electronic format this year.  The newsletter will continue to deliver updates on the progress of IC initiatives, upcoming events and training opportunities, contact details for project leads as well as our local partners and general IC news.You are welcome to use this newsletter to promote your own integrated care initiatives and we welcome feedback from you via email to

So Far,
So Good

For those of you who perhaps recall having a break over the 2016 Christmas period, we welcome you back and wish you a Happy New Year. Here’s to another year of working collaboratively to improve the quality of life for people living with Chronic and Complex conditions in supportive ways that educate and nurture staff, family and carers.

The various integrated care initiatives underway in 2016 continue to gain momentum in 2017 with many projects hitting the ground running so to speak after the Christmas break.

NNSW IC Focus for 2017:

  • Clarence Collaborative

  • Leading Better Value Care

  • Health Literacy

  • CDM Redesign

  • eMR & Safe Transfer of Care

  • Admission and Discharge Notifications V2

  • Monitoring & Performance Framework

  • Integrated Aboriginal Chronic Care

  • Provider Survey

  • HealthPathways

  • Healtenet

  • Secure Messaging

  • e-Referrals

  • Patient Centred Medical Home

  • Mental Health GP Clinic

  • Patient Reported Measures

  • End of Life Care


  • Carer/Consumer Engagement

  • Aged Care Wellness Plan

  • GP – Medical Specialist Support Line

  • GP/JMO Linkage

  • WinterStrategy 2017

  • Post-APAC Forum / IFIC & other (CHKI)

  • Paediatrics /Vulnerable families

  • Nurse Practitioner Aged Care Tweed Collaborative

  • Clarence Paediatric Development Colloborative

  • Primary Care Rapid Response – ED LBH

Have you seen the new Northern NSW Integrated Care (IC) website?


On the new site, you will find a variety of information on our current and upcoming initiatives, including contact details for project leads, opportunities to get involved and updated progress as initiatives grow.

The site will be managed and updated regularly by IC staff from NNSWLHD in consultation with the IC partners, Aboriginal Medical Services, General Practices, NSW Ambulance, North Coast Primary Health Network and as we grow patients, their families and carers as well as general members of the local community.

We welcome your feedback, you can do this via email but even better still, why not get online and contact us via the website?

Local Northern NSW Integrated Care initiatives were highlighted at the Better Together Showcase on Friday 10 March 2017 at Ballina Surf Club.

Around 100 guests attended including representatives from Department of Health, Ministry of Health, Agency for Clinical Innovation, eHealth, Northern NSW Local Health District, North Coast Primary Health Network, General Practice, NSW Ambulance and the Community.


Left: IC Showcase Persenters working – BETTER TOGETHER

Guardianship Training Day….. On 14 February 2017, Allied Health and Nursing staff from the NNSWLHD recently attended a Guardianship Training day in Ballina hosted by the North Coast Primary Health Network. Key learnings from the day included….. Read more

“It’s Now or Never”

Meaningful Conversations at End of Life Care

End of Life Care Project Officer, Anna Law is running regular workshops entitled – “It’s Now or Never”.

The purpose of the Education Day is to provide knowledge and skills for clinicians to enter into end of life conversations with their patients and loved ones – therefore aiding the smooth transition to the end of life phase for their patients. The aim is to have scores of invigorated champions leaving the training room ready to advocate for people in need of end of life care… Read more


Left: Enthusiastic “It’s Now or Never” participants pose for a picture after a workshop at Lismore Base Hospital

HealthPathways Update – What HealthPathways achieved in 2016!

Integrated Aboriginal Chronic Care
What are we trying to do?

To understand and improve the patient journey between all Aboriginal specific chronic care services in Northern NSW geographical areas, between Grafton and Tweed Heads, to develop and implement Integrated Aboriginal Chronic Care (IACC) with partner services… Read more


Welcome to Ragina Rogers (pictured above); newly appointed Integrated Aboriginal Chronic Care Coordinator… Read more

The Joint Approach project

What is The Joint Approach project?

The Agency for Clinical Innovation (ACI) has provided funding for the enhancement of a conservative or non-surgical management opportunities for clients with hip and knee osteoarthritis in the Tweed region for a period of 12 months.                                                        

Why is this important?… Read more

Chronic Disease Management (CDM) Service

Email Points of Contact Have Changed:

CDM referrals in the Richmond Valley area:

CDM referrals in the Clarence Valley area:

CDM referrals in the Tweed Heads area:

Patient Reported Measures Online Modules

The Patient Reported Measures (PRMs) program has recently developed an online capability development program consisting of a series of modules. Each module will take between 30-60 minutes to complete and are free… Read more