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Winter Strategy

The Australian Institute of Health and Welfare studies potentially preventable hospitalisations as a measure of primary care effectiveness. Patients diagnosed with chronic conditions, such as asthma, chronic obstructive pulmonary disease, congestive cardiac failure, diabetes, and hypertension, are at higher risk of deterioration and hospitalisation over the winter period.

We have implemented successful Winter Strategy programs over the past three years.

Our Winter Strategy has two significant components:

  1. General practice collaborative program, which is delivered across a seven to eight month period. The aim is to support practices in delivering proactive care for patients identified at high risk of being unwell and/or admitted to hospital during the winter (and influenza) season. Through this project practices can expect to improve care for vulnerable patients and implement quality improvement strategies.
  2. Aged care: influenza and COVID vaccination program in participating aged care facilities across the region. Registered nurses working in aged care are offered a scholarship to complete the immunisation accreditation course with ACN, and facilities are supported through a vaccination program for both their staff and residents. For more information visit our RACF Winter Strategy webpage.

General Practice Winter Strategy

Winter Strategy aims to support general practice in improving the management of patients with chronic conditions by implementing important preventative care measures to minimise their risk of hospitalisation. Patients are encouraged to be equal partners with their care team to better manage their chronic conditions, avoid hospitalisation and stay as well as possible during the winter months.

Benefits to your practice

  • Participation and outcome payments for the practice (up to $7,500 excluding GST)
  • Increased awareness of chronic disease support for your patients
  • Contributes to QI requirements for both accreditation and PIPQI


During the Preparation Phase of the program, practices recruit and maintain a register of at least 20 eligible patients to participate in the program. Patients eligible for the program need to:

  • be adult patients (18 years or over),
  • have two or more chronic conditions,
  • have presented to hospital in relation to their chronic illness/es in the previous two years, or be at risk of hospitalisation in 2023, and
  • be likely to benefit from participation in the program to reduce their risk of hospitalisation.


Once the register of patients is established in the Preparation Phase, practices enter the Implementation Phase of the program and complete the measures for each enrolled patient:

  • GP Management Plan +/- Team Care Arrangement, or undertake GPMP/TCA review as appropriate
  • Shared Health Summary updated and uploaded to My Health Record
  • Influenza Immunisation
  • Pneumococcal Immunisation (if applicable)
  • Action Plan relevant to the patient’s chronic illnesses (if applicable)
  • Domiciliary Medication Management Review (DMMR), also known as a Home Medicines Review (HMR) (if applicable) 

GP Experience of their participation in Winter Strategy

“Like other practices within our region we have many patients with chronic and complex health problems and this program offered the opportunity to be really proactive in their care and management. The aims of the program were really well defined and we found it easy to identify patients that were at high risk of hospital admission or major sickness throughout the winter months. Using Top Bar with our practice software then helped identify the patients that we enrolled in the program and complete the necessary criteria. We have found that the additional time spent with the patient has been invaluable in updating medical notes, ensuring medications are reviewed, immunisations are up-to-date and care plans are given to patients to use in case of hospital admission. We are hoping that we will see a significant reduction in presentation to the Emergency Department from these patients over the winter months due to our proactive and multidisciplinary approach to managing their healthcare needs.” - Dr Kate Brunton - McGraths Hill Medical Centre

If you are interested in joining our winter strategy program, complete the expression of interest form below: 

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