Care Pathways

INW PCP Cardiac Services Review Collaborative Project

Increasing prevalence of cardiovascular and other related health complications, combined with growing service demands, were the impetus for Inner North West Primary Care Partnership (INW PCP) member agencies to agree to work together on developing a more coordinated approach to service delivery.

This project aligns with INW PCP Strategic Priority 2: improve system capacity to increase prevention and support people from priority populations with chronic disease and its co-morbidities.

Project Goal

Project partners will work together to improve current pathways of care for populations with cardiovascular disease, whereby consumers can access the right service, in the right setting, at the right time.

Project Priority Focus

The transition of cardiac care from cardiac rehabilitation programs to primary care and ongoing health maintenance programs has been prioritised for system level improvement work in 2015, following a Client Journey Mapping Workshop in November 2014.

Project Objectives

Project objectives have been formulated following a period of problem analysis and needs identification undertaken with project partners in the initial phase of the project.

 Problem Identification and Needs Analysis Phase:

    1. A group of local agencies/programs formed a partnership and committed to work together to improve pathways of care for people with cardiovascular disease.
    2. Project partners mapped the services available for cardiac care in Melbourne’s Inner North West, enabling a better understanding of the local cardiac service system and analysis of system improvement opportunities.
    3. Project partners engaged in a Client Journey Mapping Workshop to analyse the cardiac service system from the consumer perspective, in order to further refine the scope of improvement work to be undertaken by the project.

Implementation Phase:

    1. Project partners will analyse and reach consensus on referral criteria, prioritisation of need and service coordination processes for the transition of clients from cardiac rehabilitation (phase 2) to primary care (phase 3) to enable collaborative development of a local cardiac referral pathway.
    2. Project partners will promote the local cardiac referral pathway developed with local services in Melbourne’s Inner North West, in order to increase access to primary care and community based programs by people who require support to manage their cardiovascular disease.
    3. Project partners will collaboratively develop a local agreement for service coordination arrangements within and across services including information sharing, referral and acknowledgement processes and health literacy responsiveness.

Contact:  Project Coordinator Emily Buchanan

Cardiac Referral Pathway for Service Providers

INW PCP Cardiac Services Review Collaborative Project Final Report (2016)

Diabetes Services Review Collaborative Network

A group of acute and community health agencies that provide services for people with type 2 diabetes within Melbourne’s Inner North West partnered to undertake a local inter-agency approach to creating system level change, with the aim that people with type 2 diabetes receive the right service, at the right time, in the right setting. This project was completed in 2013.


  • A planning workshop, involving eleven local agencies, identified current service criteria, practice issues and barriers to improving diabetes care in the catchment. Five key improvement strategies were prioritised.
  • The INW PCP coordinated a twelve month program of action oriented workshops, supporting agencies to work on implementing these improvement strategies.
  • The ‘Plan, Do, Study, Act’ (PDSA) quality improvement framework was used to guide the planning and implementation process.


Throughout the twelve workshops, participating agencies achieved the following results:

  • Built a shared understanding of local system and practice changes required to improve service coordination and care for clients with type 2 diabetes
  • Formed a strong professional network between local diabetes service providers and common ground for future service improvements
  • Two public hospitals in the catchment agreed on common referral criteria for outpatient diabetes clinics, and referral pathways for people who do not meet the criteria
  • Developed an agreed type 2 diabetes referral pathway in Melbourne’s Inner North West
  • Developed a local inter-agency agreement, outlining an expression of commitment and agreed guiding principles for ongoing use of the referral pathway

Project partners now meet quarterly in the form of a Network to share information and progress diabetes service system improvements fostering the Hospital, HARP and Community Health network created through the project. If your agency is interested to join this Network, please contact Project Coordinator Emily Buchanan

The Adult Diabetes Referral Guide is a living document and will continue to be updated as required.


INW PCP Diabetes Services Review Collaborative Final Project Report (2013)


An evaluation of post project outcomes was recently undertaken, with the following key findings.

The collaborative improved coordination of care for local people with diabetes within the member agencies, as demonstrated by:

  • Facilitating ease and confidence with which referrals could be directed between its collaborative members – particularly between hospital and community health services
  • Increasing volume of referrals from hospital into community health services according to the referral guide developed
  1. Referral from one hospital to one community health service (CHS) more than tripled from 2013 to 2014
  2. One hospital reported that the referrals out to community health services increased  78 Fold (0 in 2011 to 78 in 2014) resulting in an increase in new client appointments
  • Referral acknowledgments were made for 72% of referrals. Acknowledgements within the collaborative were significantly higher than the average acknowledgements returned from other services outside the collaborative.
  • The collaborative project saved resources and time through improving availability of appointments for clients requiring diabetes education in the hospital setting.
  • A project that has been sustained for 4 years with engaged and devoted members that have mutual respect for each other.

For further information the Executive Summary is available here

Contact: Project Coordinator Emily Buchanan