Overview of our CESPHN Programs

Person Centred Medical Neighbourhood Program (PCMNP) 

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PCMN Program is an opportunity for practices to adopt a more innovative model of care delivery by focussing on the needs of the patient first and using teams, practice data and effective communication to improve service delivery.  This is known as a 'person centred care' model. Person centred care is about delivering the right service to the right person in the right place at the right time.  It is about proactive care - not reactive care.  Person centred care often involves practice transformation, but we believe that this model of care can help our health system cope with increasing demands and decreasing relative resources.

The PCMN Program will support participating practices to modify and adapt their patient care and business systems. 

The Program offers:

Ongoing support of a Quality Improvement Program Officer

  • Face to face training
  • Workshops
  • Clinical leadership training
  • Assessment of the readiness of your practice
  • Quality improvement resources and tools from CESPHN
  • Upskilling in:

    - the new funding models

    - becoming champions of change and implementing CQI within your practice

    - managing and improving the way you manage your population health for your practice.


We also believe that the PCMN model of care is facilitated through our other programs in the way we support primary care into the future.

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If you would like to find out more about The PCMN Program, please contact Catherine Scardilli Program Lead for PCMN on 9304 8737 or email: c.scardilli@cesphn.com.au


Practice Support and Development



The RACGP has developed the Standards for general practices (5th edition) with the purpose of protecting patients from harm by improving the quality and safety of health services. The Standards support general practices in identifying and addressing any gaps in their systems and processes.

The Practice Support and Development Team offers support to General Practices going through Accreditation. This support may include:

  • providing advice, support and resources on meeting and understanding the RACGP accreditation standards
  • advising on key aspects of accreditation including infection control, sterilisation and cold chain management
  • delivering mock accreditation visits prior to a practice’s survey visit

Being prepared for Accreditation:

This will help take the guess work out!

Other support: includes Practice Management issues; systems improvement; orientation for Practice Staff, Practice Nurses and GP Registrars and support around practices wanting work on quality improvement activities including QI PIP.

For more information contact





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Our specialised immunisation team is there to assist your practice with all things relating to immunisation from cold chain management to accurate recording of immunisation encounters in the Australian Immunisation register (AIR) and more. Our three main areas of support are:

  • National Immunisation Program

Assisting your practice to deliver immunisation services in accordance with the National Immunisation Program and the NSW Immunisation Schedule. This may include dissemination of important immunisation related information in a timely manner to general practice, introduction of immunisation program to new practice nurses and guidance on where to look for assistance with specific vaccination requirements for your patients.

  • Cold chain education and support

Our team can provide cold chain education and support to assist your practices in developing a policy and procedure to maintain high standards of vaccine storage and cold-chain management in accordance with National and State Guidelines to ensure vaccine efficacy for the community.

  • Australian Immunisation Register education and support

We can also assist your practice to adopt a sustainable approach to reporting all immunisation encounters to the Australian Immunisation Register (AIR) and optimise child immunisation coverage rates through review of overdue children and recall and reminder services.

For more information email: Immunisation@cesphn.com.au



Digital Health

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Data quality is a pre-requisite for quality improvement and population health management. The use of information technology enables the “what you can measure, you can manage” approach to quality improvement (QI).  POLAR (Population Level Analysis and Reporting) and PEN CAT data analysis tools allow practices to improve data quality of patient records, particularly accredited practices wishing to comply to RACGP standards. Benchmarking reports are regularly provided to practices using POLAR, tracking their progress against RACGP data quality indicators and how they compare to CESPHN “average”. QI tools assist practices with the clinical management of patients by identifying patient cohorts eligible for various clinical initiatives (eg 70 years + eligible for shingles vaccine) or those with gaps in clinical care (eg no HbA1c recoded for patients for diabetes) and potentially improve practice business outcomes.  Quality Improvement PIP will be introduced in May 2019 to drive continuous QI in practices, having either POLAR or PEN will be essential as will be sharing de-identified data with CESPHN, which will provide practices with continuous QI support.

For more information contact digitalhealth@cesphn.com.au 



My Health Record



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My Health Record is the first of seven priorities which form the basis of Australia’s National Digital Health Strategy: Safe, seamless, and secure: evolving health and care to meet the needs of modern Australia. All Australians with a Medicare card or DVA card will have a My Health Record in 2019, unless they choose not to have one.


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Benefits of the My Health Record system are significant and threefold- to healthcare providers, their patients, as well as the healthcare system and underpins the enhancement of safety, quality and efficiency of an integrated healthcare system:

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To support General Practices with the usage and integration of the My Health Record system into their clinical workflow, CESPHN will be holding a series of CPD workshops around My Health Record enablement and participation. GPs will be provided with a thorough overview of the latest technologies and tools available to support appropriate, meaningful use and application of My Health Record through clinical software with relation to 5th edition standards, QI PIP and appropriate, meaningful use of data extraction tools in order to improve the quality of clinical data and in turn improve the quality of patient care and safety.

In addition to workshops, ongoing support is also provided in various forms: face-to-face training, remote support, newsletters, tools and resources.

For more information contact  the MHR Team T: 1300 986 991, dial 2 to reach MHR team or E: myhealthrecord@cesphn.com.au


Population Health 

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CESPHN has a range of population health and chronic disease programs for building capacity of our primary care providers and providing services that contribute to person-centred and led health care.

We address identified gaps and needs experienced by primary care providers and patients through commissioning a number of services. Examples of key programs and activities are:

  • Supporting general practices in Quality Improvement Activities in key areas including Cancer Screening and Sexual Health
  • Supporting primary care providers with education sessions and resources on current major healthcare reform such as NDIS
  • E-Learning for General Practice Nurse: free online learning modules for practice nurses on chronic disease management and integrated team care
  • Think, Eat, and Move (TEAM) Program: 8-week online healthy lifestyle program and personal health coaching for adolescents who are above a healthy weight. 
  • Stay Healthy Living Well Program– a free 12-week health literacy program to support your senior patients with a chronic condition and recent experience of an unplanned hospital admission. The program involves virtual education and coaching sessions, and vital signs monitoring.