Overview
Initiative type
Service Improvement
Status
Deliver
Published
June 2026
Summary
The 'Chronic Conditions Clinic' is a co-designed Western Queensland Primary Health Network-funded program, delivered by North West Hospital and Health Service (HHS) and Royal Flying Doctors' Service (RFDS), that enhances chronic conditions care in Dajarra.
Implementation sites: Dajarra Primary Health Clinic (Western Queensland Primary Health Network)
Dates: January 2025 - ongoing
Partnerships: Royal Flying Doctor Service (RFDS)
Aim
The aim of this program was to create a demonstration model that addressed gaps systematically and proactively; built capacity for early intervention in primary health care; and focused on Value Based Health Care in Chronic Conditions management.
Outcomes
- Increased collaboration and strengthened the working relationships between WQPHN, NWHHS, and RFDS.
- Highlighted the complexity of the community where most patients had six to nine chronic conditions.
- Demonstrated the diversity of the chronic disease burden; many patients had occurrences of common chronic conditions such as T2DM, Hypertension, but there have also been many uncommon and unusual chronic conditions treated under this clinic.
- Established that there are children living in the community with one or more chronic diseases (despite the small population size of approx. 200 people)
- The clinic has encountered 70 different chronic condition types in six months
- Total number of chronic conditions is 152
- 93% patients identify as Aboriginal or Torres Strait Islander
Background
In 2024 Western QLD Primary Health Network (WQPHN), in collaboration with multiple stakeholders, undertook a Joint Regional Health Needs Assessment (JRNA).
The JRNA document details the key findings from a comprehensive, systematic, and collaborative mixed-methods approach to identify the health and service needs impacting the various communities in the Western Queensland region.
Included within the key findings of the document:
- People in the Northwest Hospital and Health Service (NWHHS) region experience high rates of all chronic diseases, in particular diabetes, chronic kidney disease, chronic heart disease, and chronic obstructive pulmonary disease.
- People within the NWHHS region require enhanced access to chronic disease screening, treatment and services to support ongoing management.
- People in the NWHHS region require support to navigate the service system, particularly people with chronic conditions and multiple morbidities.
- Services in the NWHHS region need to improve coordination both within and between service providers to enhance integration and ensure seamless healthcare.
Using these findings WQPHN began collaborating with NWHHS and Royal Flying Doctor Service (RFDS) around potential strategies to address these identified needs and gaps. Through extended consultation WQPHN, NWHHS, and RFDS co-designed the 'Chronic Conditions Clinical' as a demonstration model and nominated the community of Dajarra as the target location for the program.
Methods
This program was developed as a demonstration model and has been refined using a 'PDSA' quality improvement approach, informed by continuous feedback from clinical staff, patient outcomes, and observed service gaps.
Patient identification:
Patients were initially selected by the Director of Nursing (DON) and Clinical Nurse Consultant (CNC) at Dajarra Primary Health Clinic (PHC), based on their extensive knowledge of the community and patient health needs. RFDS supplemented this process by identifying additional eligible patients through their existing clinical databases. The combined approach ensured comprehensive capture of the community members living with chronic conditions.
Initial Appointment (NWHHS):
Each patient attended an initial face-to-face appointment at Dajarra PHC with an NWHHS nurse. This consultation included:
- Collection of biometrics and pathology
- Completion of health assessments and brief interventions aligned with the Chronic Care Manual (CCM)
- Documentation of social history and development of a GP Chronic Condition Management Plan (GPCCMP)
- Clinical notes from the initial appointment were then shared with RFDS to support continuity of care.
Medical Officer Consultation (RFDS):
Patients attended a follow-up consultation with an RFDS Medical Officer, typically scheduled at least one week after the initial assessment. RFDS provided fortnightly clinics, alternating between face to face and Telehealth delivery by a doctor known to the Dajarra community. During these consultations, the Medical Officer:
- Reviewed pathology results
- Finalised the GPCCMP and/or health assessment
- Adjusted medications as required
- Coordinated referrals for specialist care, allied health, or cancer screening
- Scheduled three, six, or nine-month review appointments
All relevant clinical documentation was then returned to Dajarra PHC to maintain integrated patient records.
Ongoing Care Coordination:
Following the initial cycle of appointments, NWHHS and RFDS jointly supported ongoing patient engagement in follow-up care and participation in lifestyle intervention activities.
Development of New Initiatives:
As service delivery progressed, NWHHS and RFDS identified several gaps and opportunities to strengthen the original model. Applying a quality-improvement approach, the treating clinicians introduced and trialled new initiatives, including:
- Expanding the clinic scope to include children with chronic conditions;
- Coordinating care for family groups to improve access and engagement; and
- Delivering chronic condition management in patients' homes.
These initiatives have demonstrated early positive impacts and have enhanced accessibility and responsiveness of chronic conditions care for the Dajarra community.
Discussion
The success of this initiative has been underpinned by strong collaboration between WQPHN, NWHHS, and RFDS. Each organisation contributed essential expertise, local knowledge, and operational capability, enabling the development of a model that was both clinically robust and responsive to the unique needs of the Dajarra community.
The integration of face-to-face appointments with Telehealth follow-up care has been an essential component of the clinic's success as this has ensured that patients could reliably access ongoing chronic disease management. In addition to this, the inclusion of a doctor already known to the Dajarra community has further enhanced patient engagement and continuity of care.
Several key lessons have emerged from the implementation of this service.
First, the clinic demonstrated the substantial burden of chronic conditions within this remote community, reinforcing the need for sustained, proactive, and culturally appropriate chronic conditions care.
Second, the program highlighted the complexity of managing patients with multiple co existing conditions - particularly in settings where continuity of care can be fragmented and specialist access is limited. The dedicated structure of the Chronic Conditions Clinic - which focused solely on chronic conditions management - has proven highly beneficial compared with traditional consultation formats, where competing priorities and time constraints often put limits on chronic disease management.
The strengths of this program are considerable. The partnership driven approach has enhanced service integration, reduced duplication, and improved communication between providers. The structured appointment sequence has supported continuity, while the hybrid appointment delivery (in-person and Telehealth) has improved accessibility.
This model has also provided a mechanism for earlier identification of emerging chronic conditions and/or deterioration in health status and has facilitated timely referrals to allied health, specialist services, and cancer screening programs.
At the current time, a key limitation of the service is ensuring patients remain engaged with the cycle of care. Maintaining the patients' engagement requires time and coordination on behalf of NWHHS and RFDS - which, as the Chronic Conditions Clinic patient database expands, could place strain on the clinicians. This is a risk that has been raised and providers are working together to monitor this and ensure that necessary changes and improvements are made as needed to mitigate this risk, whilst still meeting objective of continued patient engagement.
The model's adaptability shows strong potential for scale and transferability.
With appropriate modification(s), this service model could be effectively implemented in other remote and very remote settings where chronic conditions burden is high and access to primary care is inconsistent. Communities with similar demographic profiles, health needs, and service delivery challenges would benefit from an integrated, partnership-based 'Chronic Conditions Clinic'
Overall, this project demonstrates that a dedicated, collaborative, and flexible model of chronic conditions care can significantly enhance service access and continuity for remote communities and has the potential to be replicated broadly across Queensland's rural and remote healthcare system.
References
- Western Queensland Primary Health Network. (2024). Joint regional health needs assessment: November 2024 (Approved 16 December 2024). https://cdn.prod.website-files.com/6498e7a6f8c93e238042358e/68abdb11cc071081e468ea55_WQPHN_WQJRHNA_Report_Approved161224-compressed.pdf
Key contact
Casey McDermott
After Hours Coordinator
North-West Hospital and Health Service
Email: case.mcdermott@wqphn.com.au