NRHSN 21st Birthday Ambassador - Tabitha Jones

Patient-focused multi-d team care

Cooee April 2016 Tabitha Jones

Tabitha Jones is a pharmacist on the frontier of change in the way health care is delivered. She is the team leader in Cowra for NSW Health’s Integrated Care Strategy.

This is a multi-disciplinary approach to addressing the health needs of people at a local level.

Tabitha grew up in Young and studied at Charles Sturt University in Wagga where she was a member of WARRIAHS Rural Health Club. She is the 2015 NSW Pharmacist of the Year and also heads up Cowra’s involvement in the 2016 Healthy Towns Challenge.

In her integrated care role, she coordinates and works as part of a team that includes doctors, dietitians, nurses, social workers and other health professionals serving communities in western NSW.

Together, they are pioneering a model that is built around patient needs – not professional silos. It is a collective effort to provide the right care by the right service in the right place at the right time.

And it’s working.

“Because we work so closely as a team, we plan to do care together because it’s much more efficient,” Tabitha says. “When I go out on home visits as a pharmacist now, I might take a mental health nurse, a community nurse or a doctor with me.

“We are developing the skills of the medical and allied health team to work together toward more integrated care and we even have a dietitian involved in helping to develop shared care plans that we can then work towards as a multidisciplinary GP-led team.”

The project has five demonstrator communities in the Western Local Health District – Cowra, Cobar, Molong, Wellington and Dubbo. These sites have been focused on reducing the impact of chronic and complex diseases such as diabetes, heart and lung diseases and mental health drug and alcohol concerns.

It is now being rolled out in a second wave to five more sites – Blayney, Coonamble, Lightning Ridge, Mudgee and Walgett.

More than 550 patients have been enrolled in the first wave and it is their own goals and needs that are the primary focus of developing their care plan.

“Our philosophy is to keep patients at the centre of everything we do and to do that holistically, recognising the different skills that different team members bring to the table,” Tabitha explains.

“We consult with patients and design health care with them, not for them.”

This state-funded, local-level initiative is powered by collaboration with hospitals, Aboriginal Medical Services and other health providers.

The local GP Clinical Leader of Integrated Care is Dr Ros Bullock, a GP from Cowra and who is also Chair of the NSW Rural Doctors Network.

“I have been working in the Western Local Health District for more than 10 years, both in the hospital and general practice, and have not before seen such potential for positive culture change as is occurring at the moment,” she says.

“The concept of integrating health care is not difficult. It is as it sounds - an attempt to make the passage between primary and secondary or tertiary health care as smooth and efficient as possible.

“In so many communities it is common sense, maximising services that already exist to their greatest potential. The trick is actually doing it - kind of like trying to do a major service on a jet whilst it's in mid-air.

“It takes deliberate planning to work together across public and private domains which have traditionally been kept worlds apart by different funding models. It takes key people in a community who are well respected in all facets of a patients’ healthcare journey to talk, plan, innovate and try different ways of providing health care ultimately, together.

“It takes time, energy, and money to do all this.  The wonderful thing is that NSW Health Minister Jillian Skinner has invested time and resources in this.”

Find out more about NSW Integrated Care Strategy