Overview
Initiative type
Model of Care
Status
Deliver
Published
June 2026
Summary
Distance divides - but constructive collaboration, driven by place-based Community and Clinical Co-ordinators, is demolishing disparities and improving health and wellbeing for Far South West communities.
Dates: March 2024 - June 2026
Implementation sites: South West Hospital and Health Service
Partnerships: South West HHS Primary Care Alliance Murweh, Paroo, Quilpie and Bulloo Shire Councils, and local communities
This project was presented as a Poster at CEQ Showcase 2026 (PDF, 691KB).
Aim
The Care Collective - South West Primary Care Pilot is a Commonwealth funded project to co-develop and test innovative models of service integration and enhanced primary health pathways in the community.
Outcomes
Outcomes include: improved access and coordination in rural communities.
In addition, we found increased physio, identified breast tumours, new local services, closer inter-agency collaboration between partners and wider awareness of available services
Background
Rural and remote populations face significant challenges due to geographical isolation and limited access to care and support services compared to those routinely accessible by friends and family living in regional and urban areas.
Fragmented or seemingly low anticipated demand, combined with limited transportation / accommodation, telecommunication coverage, implications of overall time commitment and low health literacy / navigation - alongside disruptive impacts of extreme weather events - compound the tyranny of distance and potentially influence an overall reluctance to access preventative / diagnostic services or take control of conditions, resulting in co-morbidities and poorer overall outcomes.
These impacts are particularly significant in the Far South West region of Queensland, classified as Very Remote by the Modified Monash Model (MM7). To put this into context, whilst local communities are supported by dedicated MPHS and Community Clinic teams, Quilpie and Cunnamulla are both approximately 500km / 5hrs on the road from Charleville Hospital, with Thargomindah approximately 665km / 7hrs away.
In addition, available providers are also challenged in the attraction and retention of key staff in community settings and / or can access real time insights on the needs of the communities they serve through outreach and other arrangements.
With our four pilot communities experiencing lower average life expectancy, higher rates of potentially preventable hospitalisations and higher ED presentation per capita than Queensland averages, extensive co-design between wider partners, communities and consumers have informed generation of practical approaches that reflect the unique nature of local requirements (2021 combined population: approximately 5,000 people, in addition to surrounding townships).
By engaging and consulting with communities on what matters most to them, and with our partners on how we might best refocus existing individual efforts into a seamless collaborative approach, we are working together to identify the best way to support local residents access and navigate the care they need.
Through investing in a total of 5.5 FTE positions across four locations, and with enhanced joint commitment between parties to further collaborate for the benefit of the communities we collectively serve, outputs include the establishment of dedicated Community Service (administrative staff, hosted by local Council / ACCHO or SWHHS) and Clinical Care (qualified health professionals hosted by CACH, CWAATSICH, RFDS) Coordinators who are linking locals to the care services they need but cannot routinely access, improving outcomes and empowering residents to take greater control of their health and wellbeing.
Our coordinator colleagues are also proving to be essential factors in the success of the pilot, with their on-the-ground knowledge and familiarity of local circumstances proving invaluable to engage and maintain buy-in of community members in addition to helping leverage available resources and expertise and advocacy across and between organisations, so that the right kinds of service can be provided in the right place at the right time.
Methods
By starting small, thinking differently and demonstrating measurable impact, a place-based methodology offers a replicable approach across rural and remote based settings which best reflect and respond to the unique needs of individual communities.
These facilitated, insights-driven approaches generated foundational shared understanding of local context, initial priorities and guided subsequent co-design that reflect diverse local needs and aspirations. Engaging with communities and responding to their input also supports local buy-in, wider participation and engagement with service providers, reinforced social connection and operational effectiveness.
Local community surveys, alongside independent external evaluation across the lifecycle of the pilot have also been utilised to further inform and revise planning and activities with lessons learnt also informing the potential to replicate models in other parts of the South West region.
Initial engagement activities highlighted significant and longstanding gaps in each community, providing a platform and pathway to address needs that are most important to local residents - noting:
- Two thirds of clients have two or more co-morbidities, with cardiac, diabetes and respiratory conditions being the most common.
- Around two thirds of our clients are also aged over 65 - and 40% of all clients are First Nations people.
- 350 client referrals have been made to 42 different services since pilot inception to March 2025 - including Chronic Disease Nurse, Indigenous Health Practitioner, Podiatry, Cardiology, Physio, Diabetic Educators, IROC and Nukal Murra.
Emerging outcomes from independent external evaluations generated by the Nous Group also include: positive improvement in partner relations regarding joint care and service coordination; identification of true service gaps, providing opportunities for teams to further collaborate to address these as they arise; positive sentiment and trust from engaged service users and increased awareness of existing services and community events clients previously did not know were available, including in relation to Aged Care and Disability services.
Discussion
By closer collaboration between partners, community members are being better supported and connected to the right services to meet their needs, resulting in fewer preventable presentations and improved local management. Comparing client hospital encounter data in the 6-months before pilot, and in the time since joining the pilot shows that clients are attending hospital less.
The collaborative approach offers opportunities to trail and test locally focused integrated models specifically adapting to the needs of individual people living with chronic conditions in remote communities through improved access coordination closer to the home.
It also promotes shared ownership and collaboration potential between organisations and providers serving the community to be replicated across other South West localities and other HHS areas. Through the engagement and delivery stages, partner organsiations have also strived to break down perceived / historical barriers to access and with demonstrated actions are empowering local communities through providing services that matter the most to them which may be taken for granted in metropolitan areas.
The biggest driver of success has been the establishment of Community Service Coordinator and Clinical Care positions who actively serve as the key connectors within town to support people accessing health services. These dedicated colleagues, the majority of which are hosted outside of South West HHS, play vital roles in awareness, relationship building and inter-organisational planning and service promotion, in addition to being the visible focal points in community.
A further major achievement has been the development of local 'service directorie' detailing available health, disability and aged care services and providing a model template for replication across other South West communities and beyond.
Working though shared challenges and barriers, we are also building closer links with our partners and communities - for example Bulloo Shire Council has recently agreed to provide access to its Thargomindah community bus to enable residents from Yowah -100 kilometers away in the Paroo Shire - to attend health events and related functions including a forthcoming four-day Health Expo being hosted by partners. Two-thirds of scheduled optometrist appointments hosted in Thargomindah on 13 May have also been booked by Yowah residents who are able to travel at no cost.
With the beneficial outcomes of earlier detection, increased access to care and supporting the preventative care narrative potentially comes increased rates of detection - so an important output is also the fact we are shining a light on unmet need for preventative health led services in our dispersed and remote communities, allowing us to better plan, advocate and collaborate to provide health services where all Queenslanders need them the most.
Key contact
Steve Ralph
Strategy Management Officer
South West Hospital and Health Service