Better outcomes closer to home for patients with Chronic Obstructive Pulmonary Disease (COPD)

We are working with community partners to improve the care of patients with COPD through early disease identification, appropriate therapy, early intervention, access to pulmonary rehabilitation and reduced hospital admissions.

2018/19 achievements:
  • coordinated satellite pulmonary rehabilitation programs to increase access, resulting in significant improvements in function and quality of life, with with a 98 per cent completion rate by participants
  • patients completing rehabilitation reported significantly better lung function. Many felt that their disease was no longer intimidating and uncontrollable
  • 25 general practices were enrolled in the clinical audits, and 40 practice nurses attended education on spirometry, while 49 GPs received education to support diagnosis and management of COPD.

The project ended in October 2018 and was a collaboration between Metro North Hospital and Health Service, Brisbane North PHN, the Australian Centre for Health Services Innovation and Lung Foundation Australia funded by the Queensland Health Integrated Care Innovation Fund.

Keeping people healthy and at home

For over 20 years, Team Care Coordination has been providing local GPs with care coordination services for their patients with chronic conditions.

An evaluation of the program has confirmed it is effective at reducing emergency department attendances, hospital admissions and the severity of patient illness.



In the 12 months to June 2019, 241 GPs in the region across 129 practices were referring to Team Care Coordination.


During 2018/19, 1050 patients consented to receive services from Team Care Coordination.

Hospital patients supported with Staying Healthy, Staying Home

There were 339 referrals from Metro North Hospital and Health Service and 16 referrals from the Queensland Ambulance Service received by the Staying Healthy, Staying Home program.

Under the program, patients receiving care at Metro North HHS facilities who do not require urgent complex clinical services but who may benefit from support at home, may be referred to Team Care Coordination.

Dementia care in the North Brisbane and Moreton Bay region

A community that cares for dementia

Participants attending the dementia workshop in March 2019.

The Integrated Model of Dementia Care in Brisbane North program engaged consumers, carers, and health service providers in dementia awareness, education activities and a collaborative co-design process. The co-design process, along with the engagement activities, will help to inform a regional strategy for living well with dementia.

Participants attending the dementia workshop in March 2019.

During 2018/19 a total of 71 GPs received training in dementia diagnosis and management, along with staff from 14 residential aged care facilities in the Moreton Bay region who received specialised dementia training for the aged care setting.

The Redcliffe Alliance for Older People was founded and attracted 135 health professionals to five meetings; helping to improve collaboration and partnerships between acute, primary care and aged care providers in the Redcliffe region.

The Moreton Bay Dementia Directory was updated and distributed to people in the Moreton Bay region who are living with dementia, as well as their families and carers.

Staff from Brisbane North PHN, Carers Queensland, Hammond Care, Centacare, Caboolture Hospital, Alzheimer’s Queensland, Moreton Bay Dementia Alliance and Membo Noticeboard.


Coordinated care for older people