A smarter way to manage chronic disease
Patient reviews completed through Summer Strategy nurse-led clinics
Hours of direct clinical care delivered to people with chronic and complex conditions
Of patients required ongoing follow-up, with 46% referred to additional services
For people living with chronic and complex conditions, proactive care can identify emerging health needs before they become more serious.
The Living Well, Your Way Summer Strategy, delivered through MPHN and Murrumbidgee Local Health District (MLHD), supported general practices to establish nurse-led clinics focused on prevention, early intervention and ongoing chronic disease management.
During 2025-2026, the clinics completed 365 patient reviews and delivered more than 315 hours of direct clinical care. More than half of the reviews involved people aged 65 and over, 78% of patients required ongoing follow-up, and 46% were referred to additional services.
MLHD’s Caroline Holtby, A/GM Community and Aged Care, and previous Program Director leading the Summer Strategy initiative, said the model made better use of the skills already available within general practice.
“The nurse-led clinic model helped practice staff work efficiently, with nurses and doctors working together at the top of their scope, to provide proactive care to their patients,” Ms Holtby said.
Importantly, practices could tailor the model to their communities, choosing different patient cohorts and developing ways of working that suited their teams.
“The greatest impact was showing nurses, doctors and administrative staff what could be achieved by working together, in partnership with patients, to provide that wrap-around chronic disease care in the community.”
The Summer Strategy also demonstrates the broader value of the MPHN-MLHD partnership – bringing primary and acute care together to fill gaps rather than duplicate services and support more people to receive care closer to home.
“MPHN’s partnership with MLHD in Collaborative Commissioning over the past three years has shown the health system innovation that’s possible when acute and primary care providers work together,” Ms Holtby said.
“Together we can provide a seamless approach to healthcare. We can improve the experience of our patients and demonstrate that in Murrumbidgee we care about how well people live, not just how long. With a focus on enhancing wellness, and access to care closer to home, we have shown we can reduce demand for hospital services and provide optimal care in the community.”
Nurse-led Clinic at Boorowa Street Medical Practice, Young, October 2025