Metropolitan Healthy Lifestyles

The Metropolitan Healthy Lifestyles Project Model is a coordinated patient-centred approach involving early patient identification, case management and case co-ordination through general practice, trained clinic staff, supported allied health and community providers, clear clinical pathways, and monitored patients to support lifestyle and risk modification for the target groups.

The overall aim of the project is to provide practical support for people at risk of developing chronic disease, or those who have chronic disease to make informed lifestyle choices and healthy behaviour change within the Rockingham Kwinana area.

The primary target populations are those newly diagnosed with type 2 diabetes and those with microalbuminuria and the secondary target population is people with multiple risk factors for coronary heart disease.

The primary outcomes of the project are to:

· Improved response and capacity of general practice to facilitate healthy lifestyles for people newly diagnosed with type 2 diabetes, those with microalbuminaemia and people with multiple risk factors for coronary heart disease.

· Increase the identification and monitoring of the target population in primary health care.

· Develop an integrated and regionally responsive model to facilitate healthy lifestyles for people newly diagnosed with type 2 diabetes, those with microalbuminaemia and people with multiple risk factors for coronary heart disease.

To deliver these outcomes, the project will achieve the following main objectives:

· Recruitment eligible and motivated patients through General Practice who will be identified early and enrolled in the program

· Develop effective GP Case Management and case co-ordination through general practice including flexible funding arrangements, ensuring a smooth patient journey and increased patient health outcomes

· Undertake service provider mapping, enlistment and clinical pathway development and maintenance

· Increase general practice capacity through improved integration, systems, resources and education

· Increase capacity of Other Providers through improved integration, systems, resources and education

· Develop relationships and communication between stakeholders resulting in increased services integration and common protocols; and within the community resulting in increased confidence and service usage.

· Systems development and maintenance in IT, documentation and education resulting in effective Case Management, accurate data, integrated protocols and demonstrated outcomes.

· Reporting and Evaluation for the project regarding processes, outputs and outcomes.

For more information about how you or your practice can be involved phone Cliff Mason MHL Program Officer on

(08) 9439 9500 or email info@rkdgp.com.au

Australian Better Health Initiative: a joint Australian, State and Territory government initiative.