GPs at the centre of the COVID-19 response in Melbourne’s north west

  26 October 2020  NWMPHN   

An update on the North Western Melbourne COVID-19 Care Pathway.

More than 250 community-based GPs are providing an essential safety net for people with COVID-19 in the North Western Melbourne Primary Health Network (NWMPHN) region. These GPs are providing continuity of care for their usual patients who contract COVID-19, while also managing the care of patients who don’t have a usual GP.

These GPs are crucial to the success of the North Western Melbourne COVID-19 Care Pathway. This pathway was established in just three weeks in July and August 2020, and was then used as the basis for a model to roll out across Victoria. By 16 October 2020, 11 metropolitan health services and 6 regional health services had operationalised the model for their local context.

The North Western Melbourne Pathway was co-designed by the Royal Melbourne Hospital (RMH), cohealth, North Western Melbourne Primary Health Network (NWMPHN) and the Victorian Department of Health and Human Services (DHHS), supported by PwC. Western Health, Mercy Health and Djerriwarrh Health Services have also joined this Pathway. The aim of the Pathway is to improve patient outcomes by:

  1. Providing quality health care services to patients who do not need to be in a hospital environment to receive care, including through people’s usual GP/general practice
  2. Supporting GPs to proactively manage and monitor patients who are considered at low risk of deterioration
  3. Providing early intervention to deteriorating patients, reducing risk of mortality and demand on ICU beds
  4. Protecting the health of the community from communicable disease and other illnesses including healthcare workers by reducing the need for physical contact
  5. Increasing efficiencies by connecting patients with their usual GP, utilising existing primary and community care capacity, a common data platform and new, integrated and stepped care models (including remote monitoring)

NWMPHN rapidly established a proactive support model to ensure GPs had timely access to the latest evidence, guidance and referral support to care for patients with COVID-19, as well as practical training and peer networking opportunities.

More information on this pathway is available on our website and in the information sheet (.pdf) and model overview (.pdf).

Pathway results

  • As of 20 October 2020, 261 community-based GPs have managed the care of 422 patients with COVID-19. These 261 GPs are providing continuity of care for their existing patients and also providing a critical safety net for patients who do not have a usual GP. This figure does not include cohealth GPs.
  • 747 clients connected to clinical care, 9 per cent required inpatient care, 91 per cent cared for at home (80 per cent by primary care with an emphasis on linking with patients’ usual GP and 11 per cent by RMH virtual care and RMH@Home).
  • 37 per cent had no regular GP, including 26 per cent that were ineligible for Medicare.
  • 63 per cent of clients cared for at home had social support needs
  • Approximately 10 per cent of clients referred for Care Navigation for detailed case management.
  • 31 per cent required an isolation plan and referrals to support services to ensure they were able to isolate successfully.
  • NWMPHN hosted 7 case-based webinars with GPs and hospital specialists with 370 participants in attendance and 585 views online.
  • More than 2000 page views of the NW Melbourne COVID-19 Positive Pathway on HealthPathways Melbourne.

We would like to hear from practices who have feedback, concern or queries on how the Pathway is working for you and your patients. Please email us: