Overview
Initiative type
Service Improvement
Status
Deliver
Published
June 2025
Summary
Piloted in the South West Hospital and Health Service (HHS), Wellness my Way is a scalable, community-driven model for chronic disease prevention and early intervention, connecting consumers, the health system, and prevention programs.
Dates: August 2024 - June 2025
Implementation sites: South West Hospital and Health Services
Partnerships: Queensland Health's Health Contact Centre (HCC), Health and Wellbeing Queensland (HWQld)
Aim
Wellness My Way aims to activate South West communities by embedding prevention into local health and community settings and guiding people with modifiable chronic disease risks to understand, navigate, and engage with appropriate prevention programs through a single access point.
Outcomes
- Improved awareness and access to prevention, with 282 consumers engaging in the model and 252 referrals connecting consumers to evidence-based support.
- Increased participation in evidence-based services, with referrals to local SWHHS prevention programs tripling during the pilot.
- Earlier intervention, with 75% of participants at moderate or high risk of developing type 2 diabetes within the next five years.
- High participant satisfaction, with 8.2 out of 10 consumers likely to recommend the program to their friends and family.
- Strengthened local collaboration, with 'Connectors' embedding prevention conversations across community services, workplaces and healthcare settings.
Background
Chronic disease remains a leading contributor to morbidity and reduced quality of life across the South West region, with a substantial proportion of this burden driven by modifiable behavioural and lifestyle risk factors. Despite the availability of evidence-based prevention programs, participation and referral rates remain low, and many community members experience difficulty identifying, accessing, or navigating appropriate prevention options.
Fragmented pathways, limited awareness, and inconsistent integration of prevention within routine health and community settings contribute to missed opportunities for early intervention. Strengthening prevention systems requires approaches that are community-centred, accessible, and embedded within the environments where people already seek care, support, and connection.
Methods
Wellness My Way was implemented as a community-activation initiative designed to increase referrals to, and uptake of, prevention programs for people living with modifiable risk factors for chronic disease. The approach centred on embedding prevention within existing health and community settings and creating a single point of access to help consumers understand, navigate, and engage with appropriate prevention options.
The initiative began by working with local South West health services, community organisations, and social care providers to identify where prevention conversations and referral pathways could be strengthened. Prevention was embedded into routine practice by supporting staff to incorporate risk identification, brief intervention, and referral into everyday interactions. This included developing simple tools and resources, providing workforce support, and aligning prevention activities with existing service workflows to minimise disruption and maximise uptake.
A key component of the model was the development of a single point of access for prevention programs. This access point was designed to simplify the consumer journey by offering clear information, personalised guidance, and support to connect with relevant prevention options. It also served as a central hub for referrals from health and community providers, ensuring that consumers were linked to programs suited to their needs and preferences. The access point helped reduce fragmentation by bringing multiple prevention pathways together in one place.
Community activation strategies were used to increase awareness and engagement. These included outreach through local organisations, participation in community events, and targeted communication to highlight available prevention opportunities. Partnerships with local councils, community groups, and primary care providers helped ensure prevention was visible and accessible across a wide range of settings where people naturally seek support.
Implementation followed a continuous improvement approach, drawing on principles of systems thinking and iterative refinement. Feedback from consumers, providers, and partner organisations was used to adjust processes, strengthen referral pathways, and improve the usability of the single access point. Data on referrals, program uptake, and consumer experience informed ongoing improvements and helped identify where additional support or engagement was needed.
Through these methods, Wellness My Way aimed to activate local South West communities, embed prevention more deeply within everyday settings, and support consumers to more easily understand and engage with prevention programs that address modifiable chronic disease risk factors.
Discussion
The Wellness my Way (WMW) pilot has been delivered through a multisectoral partnership, delivering an adapted version of Queensland Health's Health Contact Centre's 'Way to Wellness' service, to support community-based prevention. The implementation of this model has required strong local leadership, sustained partnership, and local staff to support delivery on the ground, bringing knowledge of local context. This combination of SWHHS as local implementation partners, and HWQld's statewide prevention support has supported the translation of a system-level prevention model into meaningful community action.
A locally tailored marketing campaign complemented engagement led by 'Connectors' by increasing program visibility and reinforcing consistent messaging about WMW across the region. Locally relevant imagery, simple calls to action, and tailored implementation resources promoted the digital assessment pathway, while building capacity of organisations and community members across the region to advocate for and promote preventive health.
Together, these implementation approaches contributed to effectively reaching consumers with modifiable risk factors, including individuals at risk of, or living with, chronic disease who may not otherwise seek prevention support. Creating multiple entry points into WMW through trusted settings and relationships improved accessibility and engagement. However, implementation experience highlighted that particular population groups, such as men, required more targeted and intentional strategies.
Confidence among local staff, organisations, and “Connectors†increased over time, often through personal participation in the program or through observing positive experiences of colleagues and community members. This peer-to-peer reinforcement strengthened advocacy for WMW and contributed to strengthening community trust in both the program and the people promoting it. The sharing of positive consumer experiences within communities further supported participation in prevention.
Overall, WMW demonstrates strong potential for replication across other regional settings with high chronic disease burden. By combining local leadership, multisectoral partnerships, and community-embedded engagement strategies, the model increases community awareness, community action, and access to prevention, supporting people to stay well in the community and reducing future avoidable strain on the health system.
References
Australian Institute of Health and Welfare. Australian Burden of Disease Study 2024. Australian Government; 2024. https://www.aihw.gov.au/getmedia/40f122be-f6dd-4199-b830-dc1d389eb38c/aihw-bod-40.pdf
Australian Institute of Health and Welfare. Mortality Over Regions and Time (MORT) books. 2025. Accessed March 3, 2026. https://www.aihw.gov.au/reports/life-expectancy-deaths/mort-books/contents/mort-books
Australian Bureau of Statistics. Health conditions prevalence. Australian Bureau of Statistics. December 15, 2023. Accessed August 14, 2025. https://www.abs.gov.au/statistics/health/health-conditions-and-risks/health-conditions-prevalence/latest-release
Australian Bureau of Statistics. Search Census data. 2021. Accessed March 3, 2026. Search Census data | Australian Bureau of Statistics
GBD 2017 Risk Factor Collaborators. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392(10159):1923-1994.
Western Queensland Primary Health Network. Joint regional health needs assessment, November 2024. 2024. Accessed March 3, 2026. https://www.wqphn.com.au/our-phn/publications-and-reports
Key contact
Maitilde Byrne-Kirk
Health Promotion Officer
South West Hospital and Health Service