Avoiding unplanned readmission into hospital is important. A significant proportion of hospital readmissions are avoidable and vulnerable groups, such as older people, are disproportionally affected by unplanned readmissions. Unplanned readmissions are associated with poorer health outcomes, lower satisfaction with healthcare, and increased health system costs.
The transition process between hospital and home is risky for the patient, however it is also a phase where patients may not necessarily need the intensity of a hospital bed, nor might patients actually want to remain in hospital especially if the same level of patient safety could be assured in the patient’s own home.
Tracey Johnson is the CEO of Inala Primary Care, a not-for-profit general practice located in Inala serving approximately 7000 patients; 4400 of whom attend clinic regularly. Inala is a suburb of Brisbane, Queensland and has a population of great cultural and linguistic diversity, with just under 40% of residents speaking English at home. It is also one of Queensland’s most socioeconomically marginalised urban areas.
Australian Health Journal spoke with Tracey on the role of Inala Primary care in reducing hospital admissions.
The delivery of care in a culturally and linguistically sensitive manner across all levels of the healthcare system is seen as deficient. In an effort to improve healthcare access and equity, Inala Primary Care and the Mater Integrated Refugee Health Service (MIRHS) co-developed the Mater Culturally & Linguistically Diverse Healthcare Coordinator Service (MCHooSe).
Commonly delivered services included following up with external health services, chart reviews and helping patients coordinate external health care appointments. Surveys of primary care clinicians (GPs and practice nurses) revealed that MCHooSe improved patient access to external health services and improved patient understanding of their treatments.
The data also revealed that the primary care clinicians felt the patients’ wellbeing improved after their patients had access to the service and that patients were more likely to be compliant with attendance and treatments. Most importantly, primary care clinicians said they received communications from the hospital quicker if MCHooSe was involved.
In combination, these factors are known to reduce the risk of hospital readmissions. MCHooSe highlights the potential to improve hospital outcomes through better healthcare coordination and improved healthcare equity for multicultural patients.
Tracey also talks about the outcomes of non-dispensing pharmacists in general practice in a pilot running at Inala Primary Care. Prior health research has shown the integration of non-dispensing pharmacists in the general practice clinic has significantly reduced emergency department presentations and hospital readmissions in certain patient groups (long-term polypharmacy suffering from congestive heart failure or chronic obstructive pulmonary disease).
As part of the pilot, pharmacists are working towards averting hospital readmissions, new hospital presentations and adverse health outcomes. Formal evaluation of the pilot is currently being completed by Brisbane South PHN and Griffith University.
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Changes in MBS bulk billing incentives address GP capacity in women’s health
Dr. Sneha Wadhwani, a General Practitioner in Bondi, and Conjoint Lecturer at UNSW School of Medicine, is actively involved in enhancing women’s health services across Australia. As the Co-founder and Clinical Director of Evoca Women’s Health, she highlights the significant improvements in funding for women’s health, particularly with the new MBS bulk billing incentives, in new codes, that commenced on November 1, 2025.
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Unleashing the potential of Paramedic skills and knowledge
According to a prominent paramedicine academic and researcher, paramedics have the potential to provide much-needed care in the community, changing the traditional healthcare model. Research points to paramedics having a wider healthcare workforce impact based on their ability to identify and fix problems 24/7.
Dr. Brendan Shannon is Head of Postgraduate Programs in the Department of Paramedicine at Monash University and a member of The Australasian College of Paramedicine. His interests including refining healthcare models, to ensure underserved communities receive requisite care. These alternative care pathways, like outreach programs, can work out of hospitals to provide care in underserved communities with social and complex chronic conditions.
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Medicinal cannabis in Australia Update
According to the Australian Journal of General Practice, published by the Royal Australian College of General Practitioners, more than 130,000 medicinal cannabis approvals have been issued in Australia to date, mostly by general practitioners, with approximately 65% of these to treat chronic non-cancer pain. Despite robust supportive data from animal models, current clinical trial evidence for THC and CBD efficacy in chronic pain is incomplete. In their prescribing decisions, doctors must balance patient demand and curiosity with caution regarding potential risks and limited efficacy (Source: https://www1.racgp.org.au/ajgp/2021/october/medicinal-cannabis)
Australian Health Journal met with 3 speakers at the recent @arcsaustralia ARCS22 Conference providing an update on medicinal cannabis. The discussion with the speakers now centres on affordability and access.
