Population Health

Population Health

Advancing the health of the Darling Downs

and West Moreton population

__________________________________________

Year in review


Our PHN is committed to advancing the health and wellbeing of people living in our region.

6,580

people accessed services to help manage their chronic condition

1,033

newly arrived humanitarian entrants supported with care coordination

947

young people assisted with their sexual health

1,466

patient trips provided through the Patient Transport Program

Chronic Conditions

The Chronic Conditions Program funded by our PHN aligns with the National Strategic Framework for Chronic Conditions. The program funds prevention and early intervention  services to prevent the development of chronic conditions as well as direct service delivery and care coordination.

2,216

new referrals into chronic conditions services and/or programs

583

people exited a service and /or a program

618

group sessions were held

2,121

people attend group sessions

Our 2019-20 funded providers were: 

  • Abel Podiatry
  • AH Diabetes
  • Better Movement Clinic
  • Burnett Allied Care
  • Darling Downs Health
  • EACH
  • Friendly Feet Podiatry
  • Healthy Lifestyles Australia
  • Inglewood Community Welfare Group
  • Integrated Therapy Solutions
  • Macintyre Health World Class Diabetes
  • Margot Hawker Dietetics
  • Rapid Exercise Physiologist Specialists
  • Physiologist Specialists
  • South Burnett Physiotherapy
  • South Burnett Podiatry
  • Steve Royle Exercise Physiology
  • The Physiotherapy Centre
  • Toowoomba Podiatry Clinic
  • Total Balance Health and Fitness
  • Total Health Podiatry
  • Vincent Young Podiatrist
  • Vital Health
  • Warwick Physioworks



My health for life

My health for life helps people in our region with management and/or prevention of their chronic conditions. The program works in partnership with general practice and focuses on small lifestyle changes to achieve greater health benefits. 

3,303

risk assessments were completed 

691

residents in the region were enrolled in the program

508

completed the program 

Making a difference for our varied populations

The PHN continues to fund services for a number of vulnerable groups in the Darling Downs and West Moreton region. 

Supporting the health of our diverse population

Refugee Nurse Outreach Program


The Darling Downs and West Moreton region is home to more than 10,000 people 

from migrant and refugee backgrounds of diverse cultures, signalling a need to 

ensure support to facilitate a smoother transition to the Australian health care 

system. 


Our PHN continued to fund Multicultural Australia and Access Community 

Services to deliver the Refugee Nurse Outreach Program across the region. 

The program provides services to newly arrived refugees, including: 

  • coordinating access for clients to GPs and allied health services;
  • supporting general practice to conduct Refugee Health Assessments;
  • improving the health literacy of people from a refugee background;
  • reducing barriers to ongoing health care management; and
  • facilitating the appropriate transfer of medical information across health services.

Care was coordinated for 1,033 newly arrived humanitarian entrants.


Complementing these efforts, Carbal Medical Services were funded to ensure uninterrupted delivery of healthcare for refugees from May 2020. 

Until 30 June 2020, Carbal completed:

110

Refugee Health Assessments

414

administered vaccines

77

referrals provided for further care

Interpreting for Allied Health Providers Program

The Interpreting for Allied Health Professionals Program provides interpreting services for private allied health professionals treating patients from refugee and multicultural backgrounds across our region.


The interpreting services are delivered by a nationally accredited interpreting provider. 




In 2019-20, 672 interpreting services were provided.


Refugee Ready Healthcare Module

In 2019/20, the PHN worked with local stakeholders to develop the Refugee Ready Health Care online learning pathway to increase the knowledge and confidence of primary care service providers caring for people from a refugee background, people seeking asylum and culturally and linguistically diverse populations living in our region.


The course provides targeted, localised education for GPs, practice nurses, practice support staff and allied health professionals in the Darling Downs and West Moreton region, including local health pathways and region-specific support services, and presents the stories of local refugees living in our community. To access the learning modules, visit www.ddwmphn.com.au/online-education 

Quality care at the end of life

Toowoomba and Ipswich Hospice


Community hospices provide palliative care support for people in need of end of life care and their families. Within the Darling Downs and West Moreton region there are limited services available that provide no cost end of life care.


The Toowoomba and Ipswich Hospices are community-funded holistic hospice facilities providing end of life care. Our PHN continued to provide funding to both facilities in 2019-20 to assist with the provision of no-cost, GP- led palliative care for people at the end of their life.


The funding provided enabled both Hospices to employ suitably qualified staff, including a registered nurse and personal care worker, to give high quality clinical care and support to patients and their families. 


"The funding provided enabled both Hospices to employ suitably qualified staff..." 



Child and Youth

True Relationships and Reproductive Health

Civic Assist Street Crews

Our PHN continued to support True Relationships and Reproductive Health to deliver reproductive and sexual health care to young people under the age of 25 in Toowoomba and Ipswich through clinical services, information and education. 


In 2019-20, True supported:

645

young people in Toowoomba

302

young people in Ipswich

Civic Assist Street Crews engage with young people in Toowoomba who may be experiencing a range of concerns. These concerns can be related to homelessness, relationships conflict, family violence, medical issues, transport issues, school or education problems, and alcohol and other drugs dependence.


The Civic Assist Street Crews provide accidental counselling and a referral service allowing vulnerable and at-risk youth to engage with health and support services in a non-threatening environment.


The Civic Assist Street Crews operate in Toowoomba’s CBD from 6:00pm to late on Thursday nights with the aim of meeting vulnerable youth aged 12 - 24 in a place they feel comfortable.


Over the past 12 months, the Street Crews have engaged in over 1,200 meaningful conversations with youth.

604

 identified as Aboriginal and Torres Strait Islander

147

were from culturally and linguistically diverse backgrounds

64

young people assisted with referrals to health and community services

Accelerating access to support in regional areas 

Patient Transport Program


To support patients at risk of potentially preventable re-admission to hospital attend primary health care appointments, our PHN continues to fund regional patient care coordination and client transport services in Goondiwindi and surrounding areas.


Goondiwindi Regional Council employs a care coordinator to engage referrals and organise volunteer drivers with a donated vehicle to take residents to and from specialist health care appointments in Toowoomba with the Meditrans service.


Care Goondiwindi provides transport for residents to and from their homes to medical appointments within Goondiwindi.


In 2019-20:

1,264

 patient trips within Goondiwind has been coordinated by Care Goondiwindi’s Medico Transport Service

202

 trips has been coordinated by Meditrans for residents to access services in Toowoomba

Let’s ‘TALK ABOUT’…


To better engage with the community about their experiences with primary health care, our PHN launched the ‘TALK ABOUT’ Campaign in February 2020. 


‘TALK ABOUT’ asks the community to tell us what they think is working well, and what they think could be done better with health care in their communities. 


For 2020, four topics were selected for the community and health professionals to provide feedback on through a short, five-minute survey each quarter. 


2020 Topics are:

Check out ‘WHAT WE HEARD’ below:



Information gathered through the ‘TALK ABOUT’ Campaign is being used to inform the PHN’s Health Needs Assessment. 


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