Collaborative Commissioning: “Living Well, Your Way” - a value-based model of care in Murrumbidgee

December 2022 edition : Collaborative Commissioning

Living Well, Your Way targets people diagnosed with Congestive Heart Failure (CHF) and/or Chronic Obstructive Pulmonary Disease (COPD) who have presented to hospital.  
 
The aim is to keep people with COPD and CHF healthier at home for longer by delivering primary care and community-based services aligned with best practice. It aims to reduce the demand on Emergency Departments and hospital admissions by providing optimal care in the community.  

People in the Murrumbidgee region who experience chronic disease often experience siloed and expensive care, with regular travel and frequent visits to hospital. Living Well, Your Way will increase early diagnosis and support for people to better understand and manage their condition on a day-to-day basis. 

Living Well, Your Way also supports: 

• patients to be cared for in the community unless it is clinically unsafe to do so; 
• establishment and inclusion of a Living Well, Your Way community, comprising of all providers involved in COPD and CHF management, i.e., pharmacies, General Practitioners, private medical specialists, local health district outpatient and community services, Non-Government Organisations and private businesses; and 
• all patients having their own shared care plan, starting with a sick day action plan. 
  

There are seven steps in the program that cover care for patients with COPD and CHF from diagnosis through to end of life. More information about the steps is available on the Living Well, Your Way website.