• NURSE COORDINATED CLINICS

    Chronic disease support and strategies

    A clinic can focus on a specific chronic disease such as diabetes or
    asthma, or have a general focus on caring for people with chronic diseases
    and facilitating preventative health assessments and care planning.

Nurse Coordinated Clinics Strategies Support

Designed to provide patients with chronic disease with additional support and strategies.


A nurse coordinated clinic is designed to provide patients who have a chronic disease with additional support and strategies to self-manage their illness. A clinic usually runs in a set and dedicated time during a practice’s usual business hours, so that patients can access both nursing and GP support for their chronic disease.

Outcome Health’s comprehensive range of clinical support services improve the efficiency and viability of general practices and contribute to better health outcomes for patients.

A clinic can focus on a specific chronic disease such as diabetes or asthma, or have a general focus on caring for people with chronic diseases and facilitating preventative health assessments and care planning.

Our nurse coordinated clinics include:

Outcome Health respiratory nurse educators provide self-management skills, patient education and support, spirometry, medication education and correct device use, as well as preparing Chronic Disease Management (CDM) plans in conjunction with the GP, and following asthma cycle of care guidelines, enabling access to the Asthma SIP.

These clinics provide an opportunity for patients with chronic and complex medical conditions to have a GP management plan (GPMP) and or a team care arrangement (TCA) developed. The information in the plans then gives the patient and all health care providers involved in their care a comprehensive summary of the health issues and management. Clinics can operate as frequently as required by the practice. The nurse will work with the patient and GP to document a comprehensive GPMP/TCA and complete all relevant communication with the team members.

The Coordinated Veterans’ Care (CVC) Program is for eligible DVA Gold Card holders living in the community and focuses on improving wellbeing and quality of care for veterans who have chronic conditions such as congestive heart failure, coronary artery disease, pneumonia, chronic obstructive pulmonary disease, diabetes and other complex care needs, who are most at risk of an unplanned hospital admission.

This program requires GPs to prepare for the program, enroll participants in the program and provide ongoing care. Whilst GPs can run this program without nursing support, additional DVA funding is available to GPs whose CVC programs are supported by nurses.

Outcome Health can provide practices with a clinic nurse to manage the day to day care coordination for CVC patients, including completing a comprehensive needs assessment, assisting in preparation of their care plan, care coordination, regular calls and visits to the participant and providing feedback to the GP.

Outcome Health’s qualified diabetes nurse educators provide self-management skills, patient education and support, medication education including insulin initiation and home blood glucose monitoring, as well as preparing Chronic Disease Management (CDM) plans in conjunction with the GP, and following diabetes cycle of care guidelines, enabling access to the diabetes SIP.

Option of Credentialed Diabetes Educator - Allied Health Clinic Model

Where the diabetes clinic is run by a Credentialed Diabetes Educator, the practice may choose to run the diabetes clinic as an Allied Health service. Under an Enhanced Primary Care (EPC) plan, allied health referrals can be made to this position by the GP, and Allied Health MBS items claimed from Medicare. *Please note that if the clinic is run as an Allied Health Service, the nursing hours do not contribute to Practice Nurse Incentive Payments (PNIP).

Outcome Health can provide a nurse with the necessary skills, expertise and training to assist GPs perform health assessments in a four hour clinic session.

Practice Based Assessments

Outcome Health can provide a nurse with the necessary skills, expertise and training to assist GPs perform health assessments in a dedicated clinic session. This is one of Outcome Health’s most lucrative clinic models for practices.

Home Based Assessments

If you have patients that would benefit from a home based assessment, Outcome Health can also arrange Home Health Assessments, either on an ad hoc basis, or in a regular clinic booking. Outcome Health’s nurse will complete the assessment in the comfort of the patient’s home, and return the patient information back to the practice. The GP must then see the patient for a follow up visit to claim the relevant MBS item number. Outcome Health home-based health assessments are invoiced to the practice on a ‘per assessment’ basis.

Comprehensive Medical Assessment (CMA) for those in Aged Care Facilities

This service offers GPs an experienced practice nurse to assist with the documentation associated with completing a CMA for eligible patients. The GP completes a referral slip with relevant information. A Outcome Health nurse will visit the aged care facility to initiate the assessment process, collecting relevant information and returning it to the practice. The GP will then see the patient for a follow up visit to complete the assessment and claim the appropriate item number.

We welcome expressions of interest in our established clinics as well as suggestions for new/pilot programs, projects and support services

Benefits of Nurse Coordinated Clinics in general practice

A well managed and efficient nurse coordinated clinic can provide increased income and profit, contributing to the long term viability of your practice. Sharing the management of chronic disease patients across multiple disciplines means the GP’s time is used more efficiently, increasing their capacity to see more patients.

By using Outcome Health's nurse coordinated clinics practices have greater access to diabetes and asthma Service Incentive Payments (SIP) as well as Practice Nurse Incentive Payments (PNIP). Most importantly, nurse coordinated clinics help practices achieve better health outcomes for their patients by increasing the efficiency of practice resources and the range of services available to their patients. Patients appreciate that the nurse is on site with their GP and they can attend their usual practice for this additional service. Patients also appreciate that services are bulk billed, review appointments are easily available and nurses are able to spend more time on education aspects with them if required.

Health outcomes are reflective of improved management and quality of care for patients with a chronic disease, as well as screening, prevention, assessment, patient self management education, care planning and review activities.

Contracted hours can contribute towards Practice Nurse Incentive Payments

It is the responsibility of the practice to determine actual eligibility for the PNIP scheme with Medicare and to ensure compliance with PNIP guidelines and reporting. Outcome Health provides ongoing clinic and practice support, ensuring effective implementation, delivery and sustainability of the practice’s Outcome Health clinic. This includes regular review of the service, trouble shooting, and providing leave cover for clinics where possible. Contracts are reviewed annually or by request with the Manager – Clinical Business Development.

How can Outcome Health nursing services help your practice?
  • Would your patients benefit from accessible specialist diabetes or asthma/respiratory education on-site in your practice?
  • Would your staff and patients benefit from additional nursing support to better facilitate care planning, health assessments, coordinated veterans care, chronic disease care cycles or other general nursing support?
  • Our services are specially tailored to YOUR practice, based on your unique patient demographics, staffing arrangements, billing history and specific practice needs.
  • Our nurse-led clinics and nursing services are designed to generate income covering the cost of the service to ensure they add value to your practice, as well as for your patients.
  • The practice benefits from having highly skilled staff on-site with specialist peer support.
  • We can help make the Practice Nurse Incentive Payment scheme work for your practice.

Get in touch with us

Outcome Health’s goal is to support Primary Health Networks (PHNs), General Practitioners and other primary health care professionals