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Strengthening Prevention

Providing communities a single-entry point to chronic disease prevention.

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Strengthening Prevention in Integrated Care Systems in practice

Compared to other regions across Queensland, people living in South West Queensland are more likely to engage in health behaviours that increase the risk of chronic diseases such as type 2 diabetes and cardiovascular disease (State of Queensland, 2022). This health disparity is influenced by a complex range of factors such as socioeconomic status, health literacy, workforce shortages and access to preventive health. 

State government departments in health and prevention, local government, private health providers, community and university sectors are pioneering an initiative to transform the delivery of prevention in the community. The Wellness my Way (WmW) pilot is a localised approach that supports the community to engage in positive health behaviour change and access individually tailored support earlier in their health journey to prevent chronic disease from occurring. 

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About Wellness my Way

WmW is a digitally-enhanced prevention model of care that provides communities a single-entry point to chronic disease prevention. The pilot leverages an adapted version of the Way to Wellness service, an existing and successful statewide service delivered through Queensland Health’s Health Contact Centre (HCC).  

Through community activation, consumers are encouraged to engage in a digital health check,  followed by a telephone coaching session to support consumers to build motivation, and co-create an action plan that focuses on health goals important to them. Referrals and connection to appropriate prevention programs is discussed to enable ongoing support for the consumer to reach their health goals. 

The WmW pilot was initially planned for a 7-month implementation period in the Maranoa Regional Council area in South West Queensland (Roma and surrounds). 

The Integrated Care System

Health and Wellbeing Queensland (HWQld) led and funded collaborative efforts with Queensland Health’s HCC, South West Hospital and Health Service (SWHHS), and the Health and Wellbeing Centre for Research Innovation (HWCRI) at The University of Queensland. Leaders from each organisation helped drive the shift from commitment into action with relevant partners, the workforce and the community.  

SWHHS, together with HWQld, led a local expression of interest process resulting in 11 health and community organisations across the Maranoa Regional Council area joining pilot implementation. Each organisation (listed below) identified representatives to be ‘Connectors’ – local voices in the community that advocate for, raise awareness of and encourage participation in WmW, including hard to reach populations. This has been a powerful approach to building prevention capability and community activation. 

The pilot health and community organisations included:

  • DrugARM 
  • Maranoa Regional Council 
  • Mitchell Community Advisory Group (SWHHS) 
  • Queensland Ambulance Service 
  • RHealth (Medicare Mental Health) 
  • Roma Primary and Community Care 
  • SWHHS Healthy Communities Team 
  • Stride 
  • Surat Medical Practice 
  • UnitingCare 
  • Vital Health. 
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Together, collaborative partners and connectors have been involved in the co-design, implementation and evaluation of the WmW pilot, underpinned by The Framework’s guiding principles. 

Applying The Framework

To maximise reach and program benefits, in month 4 of pilot implementation, collaborating partners agreed to extend the pilot to the broader SWHHS region for a total 11-month implementation period.   

At the 6-month mark, HWQld presented preliminary findings to the SWHHS Chief Executive, celebrating progress and sharing early insights including the growing local momentum for prevention. The Strengthening Prevention in Integrated Care Systems’ 6 building blocks were used to guide discussions on the longer-term sustainability of WmW in the region, with a focus on strengthening ‘shared leadership and responsibility’ and exploring ‘investment and collaborative funding models’ moving forward. The discussion led to in-principle commitment from collaborating partners to extend WmW implementation for an additional 12 months, with SWHHS contributing increased workforce capacity and funds to sustain a place-based approach to implementation.   

Following is an example of how the 6 building blocks currently apply to the WmW program.  

Health literacy and activation

  • Activating the community and building momentum for preventive health 
  • Delivering an accessible consumer-led pathway for people to ‘check in’ on their health, nudging readiness for change, developing person-centred action plans and supporting navigation to prevention programs.

Reorient service delivery

  • Providing a simple way to engage consumers in preventive health via a single digital ‘front door’ with support from a skilled phone coaching workforce, reducing burden on frontline clinicians. 
  • Enabling access to preventive health within and beyond traditional health settings. 
  • Reaching people earlier in their health journey, including those who may not proactively engage with health services for preventive health.

Workforce capacity and capability  

  • Building preventive health capacity and capability across health and community settings for long term sustainability. 
  • Leveraging traditional and non-traditional workforce via place-based marketing and ‘health and community connectors’. 
  • Building skills in motivational interviewing and increasing awareness of referral pathways to statewide and local prevention programs.

Data, technology and innovation  

  • Utilising an existing, successful statewide service and expanding its reach into the community with a key focus on prevention. 
  • Applying a data driven approach to implementation of WmW that is responsive to feedback and enabled for iterative improvements and ongoing evolution.

Shared leadership and responsibility  

  • Maintaining effective collaborative partnerships and strengthening governance processes with: 
    • HCC – leveraging a statewide service, Way to Wellness, including the infrastructure  
    • SWHHS – supporting place-based implementation  
    • HWCRI – strengthening evaluation and research.  
  • Exploring opportunities to diversify and formalise partnerships towards an enduring local Integrated Care System.

Investment and collaborative funding models

  • Co-funding established between HWQld and SWHHS to extend implementation in South West Queensland for a further 12 months. This includes investment in the HCC for delivery of the adapted version of the Way to Wellness service, as well as investment in place-based marketing approaches. 
  • Continuing collaboration partnership with HWCRI, a co-funded research centre partnership between HWQld and The University of Queensland, to enable robust evaluation and research.
  • Exploring future opportunities for collaborative funding to support sustainability. 

Learn more about The Framework and the Wellness my Way program

References:

1. State of Queensland (South West Hospital and Health Service) Local Area Needs Assesment (2022)

Last updated 26 May 2025