Optimal care

Brisbane South PHN supports three key components essential for improved primary care management of chronic disease: delivery system design, clinician decision support and patient self-management support.

Brisbane South PHN supports general practice to provide ‘Optimal Care’ to people with chronic disease through quality improvement initiatives.

The Optimal Care program assists general practice staff to identify areas in their chronic disease management that they would like to improve or make changes for the benefit of patients and the practice. This support occurs through the provision of resources and workbooks, and Optimal Care Program Support Officers who assist practices to implement the quality improvement initiatives.

Optimal Care provides the following support:

  • advanced training in the use of the PenCS patient data extraction system for chronic disease management
  • improved practice data quality and analysis for quality improvement
  • understanding of chronic disease and prevention related MBS item numbers including PIPs
  • best practice guidelines and clinical decision support tools
  • the use of screening tools e.g. diabetes risk assessment tool (AUSDRISK), cardiovascular risk calculator
  • coordinating patient care through the use of SpotonHealth Healthpathways.

General practices will receive:

  • support and education from the Optimal Care team via different methods (face-to-face, phone support, in-practice education and group events)
  • monthly practice data reports sent straight to your inbox
  • disease specific program workbooks to help guide you through your quality improvement
  • in-practice upskilling from specialist clinicians (eg respiratory educator).

For further information or to arrange for an Optimal Care Program Support Officer to visit your practice email optimalcare@bsphn.org.au or phone 3864 7551.