Among the focus for Western Sydney Primary Health Network and our partners, has been the development of strategies which seek to address chronic condition prevention and management through better coordination and integration of services between the primary (general practice) and acute (hospital) sectors.
Starting 1 July 2025, there will be changed to the Medicare Benefits Schedule (MBS) for managing chronic conditions (subject to legislative approval). Click here to find out how these arrangements simplify and streamline the current MBS arrangements and integrate MyMedicare.
Health professionals: major MBS changes to chronic care start 1 July 2025. Access the CCM Toolkit now to prepare your team, update workflows, and lead the change.
What are Chronic Conditions?
Chronic conditions are characterised by complex causality, multiple risk factor, long latency periods, a prolonged course of illness and functional impairment or disability. Most chronic conditions don’t resolve spontaneously and are generally not cured completely. Chronic conditions such as diabetes, heart disease and asthma are amongst the leading causes of death and disability in Australia. The most socially disadvantaged areas often have the highest prevalence of chronic conditions. The rate of chronic conditions in Western Sydney is quite high with diabetes being higher across many areas in Western Sydney, compared to the national diabetes prevalence rate.
Diabetes
With Western Sydney regarded as a diabetes hotspot, the need for a coordinated and whole-of-system approach to its prevention and management was recognised by the community. Working in partnership, the Western Sydney Primary Health Network, along with Western Sydney Local Health District, consumers and health professionals, established the Western Sydney Diabetes (WSD) Alliance to reduce the burden of the condition. WSD initiatives include routine HbA1c screening, Diabetes Case Conferencing, 2kg Challenge and Walking Groups. More information is available on our Western Sydney Diabetes webpage. Additional programs we provide are:
Delivered to people in Western Sydney who have pre-diabetes or are in the early stages of type 2 diabetes, Shared Medical Appointments (SMA) are consecutive individual medical visits carried out in a supportive group setting of similar patients where all can listen, interact and learn. The program will be delivered in six general practices in Western Sydney to develop and trial an SMA package in pre-diabetes and early-stage type 2 diabetes prevention, mitigation and management.
Too Deadly for Diabetes is a 10-week program that supports Aboriginal and Torres Strait Islander community members living with, or at risk of developing, type 2 Diabetes. Expertly facilitated by one of Australia’s leading health professionals Ray Kelly, the program provides participants with a meal plan, exercise program, education, and motivation with the aim of losing weight, improving health, and reducing diabetes risk factors.
Hear the testimonials of some of the program’s participants: Too Deadly for Diabetes in Emerton
To find out more about these activities contact the Commissioning team at commissioning@wentwest.com.au
The Pasifika Preventing Diabetes Program (PPDP) is a lifestyle diabetes prevention and management program for Samoan communities delivered through churches. The program aims to build support to help facilitate lifestyle changes on a day-to-day basis. PPDP utilises person-centred motivational interviewing, peer support facilitation, community coach facilitation, lifestyle ideas to encourage sustainable healthy lifestyle change, educational and behaviour change support strategies and diabetes management strategies.
For more information, visit the Western Sydney University website.
We also have a range of free resources on diabetes management and prevention available online. Health professionals can access Western Sydney HealthPathways (unique username and password required).
The Royal Australian College of General Practitioners and Diabetes Australia have united to support GPs in their management of type 2 diabetes through Management of type 2 diabetes: a handbook for general practice.
Cardiology
Every 30 minutes, one Australian loses their life to a heart condition, yet it takes less than 30 minutes to conduct a heart health check and prevent this. In Western Sydney, many people face significant heart health challenges and have a higher chance of developing cardiovascular conditions compared to other regions.
The Western Sydney Cardiology program is a collaborative effort designed to improve the early detection of cardiovascular conditions. The program also supports the management of heart conditions such as atrial fibrillation to prevent serious illness and reduce the need to go to hospital.
For Health Professionals, visit our Western Sydney Cardiology webpage
For patients, visit the Heart Foundation’s Your Heart webpage for trusted information on heart health, risk factors, prevention and support for living with heart disease.
Hepatitis
Western Sydney has the fourth highest prevalence of hepatitis B in the country with an estimated 13,089 people living with chronic hepatitis B. Only 19% of people living with hepatitis C have initiated treatment, making the region the second-lowest in NSW.
With effective treatments available to help manage hepatitis B and cure hepatitis C, Australia is leading the way for a future without viral hepatitis.
We’re working collaboratively with the Western Sydney Local Health District (WSLHD) to address the burden of viral hepatitis by supporting health professionals and community members across Western Sydney.
We also have a range of free resources on hepatitis treatment available online. Health professionals can access Western Sydney HealthPathways (username and password required) and community members can access Healthy Western Sydney.
Motivate C, is an HREC-approved, Australia-wide project evaluating the use of financial incentives to increase uptake of hep C antiviral therapies in primary care. The project is currently recruiting people living with chronic hepatitis C infection who have not initiated treatment. Primary care providers can find information resources for hepatitis C testing and treatment under GP FAQs. The Project team can be contacted on motivatec.project@sydney.edu.au
Hepatitis NSW have developed some great videos on hepatitis to help explain what it is and how treatment can help:
Fitness and Physical Activity Initiatives
The 2kg Challenge is an eight-week lifestyle program designed to help patients reduce their risk of type 2 diabetes. Evidence shows that losing just 2kg can lower diabetes risk by 30% in at risk individuals.
How Health Professionals Can Get Involved:
- Refer eligible patients at risk of type 2 diabetes
- Support behaviour change with free coaching, exercise, and diet resources
- Encourage patients to engage through texts, emails, and videos
Encourage your patients to take the first step. Visit the 2kg challenge webpage here.
To enhance access to exercise within the Western Sydney community and address prevalent issues like low physical activity and high obesity rates, we’ve collaborated with Live Life Get Active (LLGA) to offer free fitness camps and exercise classes in the region. These 45-minute sessions include yoga, boxing, and cross-training, catering to various fitness levels.
Fitness Camps and Online Classes
LLGA provides both face-to-face fitness camps and online exercise classes. In-person sessions are conducted at multiple locations across Western Sydney, while online classes are available as daily live streams and on-demand videos. Participants can also access resources on nutrition and wellness through the LLGA website. All offerings are free of charge.
Social Prescribing for Health Professionals
Social prescribing enables health professionals to refer individuals to non-clinical services that support overall well-being. To refer patients to LLGA’s programs, please visit the LLGA website for more information.
For further details and to register for classes, visit the LLGA website.
We’ve partnered with the Heart Foundation and Western Sydney Diabetes to encourage patients to take part in patient-led walking groups aimed at improving overall health. These groups offer a low-cost, effective way to increase physical activity—supporting diabetes management and prevention, reducing the risk of heart disease, and helping with weight control. You can download a list of Walking Groups in Western Sydney here or visit the heart foundation website here to find a local group or start your own walking group!
General Practice Pharmacist
The Western Sydney General Practice Pharmacist Program involves the integration of pharmacists into general practices in Western Sydney to work collaboratively as part of the patient care team and forms part of a collaborative, patient-centred primary care model. The project was designed in partnership with the University of Sydney and is supported by the Western Sydney Local Health District.
A General Practice Pharmacist (GPP) is a non-dispensing pharmacist who delivers clinical and education services to patients within the general practice setting. The GPP is integrated as a member of the patient care team to foster true team-based care and support the Patient Centred Medical Home principles. Their role complements the dispensing role undertaken by community pharmacists but can bring core pharmacist skills into the general practice setting.
Integrated Care Program
The Integrated Team Care (ITC) Program improves health outcomes for Aboriginal and Torres Strait Islander people with chronic health conditions through access to care coordination, multidisciplinary care and self-management support. It improves access to culturally appropriate, mainstream primary care services, including general practice, allied health and specialists. The program also provides cultural awareness training to medical professionals. Find out more on the website.
Progressing Health Now
Find out more about other Programs and Priorities for Western Sydney.
