Lynne takes the lead on chronic disease

Nurse leads the way with patient-centred care

Source: APNA Primary Times Spring 2020 (Volume 20, Issue 2)

Orange is a city of 40,000 people in Central West New South Wales. Like many country centres, it has its fair share of health challenges.

But an innovative nurse-led clinic, backed by enlightened doctors, is making a substantial difference to the health and wellbeing of the community as well as to people in surrounding small towns.

APNA member Lynne Lambell, a Registered Nurse with 44 years’ experience in rural NSW, heads up the Wellness Clinic which operates out of the Wellness House medical centre.

It is here that Lynne and another nurse coordinate the care of more than 1,000 patients with chronic disease.

They aim to improve the health of these people by encouraging lifestyle changes, organising treatment by other health professionals and increasing general health literacy so patients can manage their own health more effectively.

For Lynne it literally is a labor of love as she has developed a strong connection with the people she sees.


“These patients are my community,” she says. “Hearing their stories helps me understand how I can provide care for them.”


Those stories run the gamut of chronic disease from diabetes, to heart problems, chronic obstructive pulmonary disease and mental health. The latter was exacerbated by the impact of a four-year drought.

Many of the patients she sees are from lower socio-economic backgrounds, including members of the local Indigenous community who have a significantly lower life expectancy compared to the rest of the NSW population.

The team approach to patient care and the nurse clinic are supported by Dr Alex Hoyle, who says Wellness House seeks to “focus on health, rather than illness”.

“As doctors, we focus a lot on the numbers, on the medication, on the illness because that’s our training,” he says. “Whereas I guess with nursing, the focus is more on symptoms, activity and social coordination.

“Having that kind of two sides to the equation really allows us to do a far more kind of integrated assessment for the patients with health plans and achieve positive outcomes.”


When Lynne started the clinic, she undertook comprehensive data cleansing using PENCAT software. Patients with three or more co-morbidities were identified and a disease register was created.

Brochures introducing the nurse clinic were handed out to patients by reception staff and the word soon got around. A big attraction for people on low incomes was bulk billing. All consultations are bulk-billed utilising eligible MBS chronic disease items and there is no out-of-pocket expense to patients visiting the nurse clinic.

Initial 45-minute appointments to discuss health concerns and care planning allowed time for Lynne to gather information about the patient and provided a holistic insight to their individual health needs and goals.

“I like to start by finding out what matters to them so we can set some goals and help them – listening uncovers all kind of things where we can make a difference. It could be helping them access better quality, low-cost food or arranging transport to chemo appointments. The person and their needs are very much at the centre of what we do.”


Care plan development and GP consultation for identified treatments, medication and pathology attracted MBS funding. A follow up 30-minute appointment to check the progress of any referrals to additional services and to track and review patients’ care plans was scheduled.

In its first 12 months, the clinic had more than 1,100 appointments. “It’s been pretty full on,” says Lynne. “There’s also a lot of chasing up to make sure people are on top of things, checking in on the over-75s - but it is so worthwhile.”

This nurse-led clinic is funded through APNA’s Building Nurse Capacity program, an initiative of the Australian Government Department of Health.


Find out more about the Building Nurse Capacity program

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The Australian Primary Health Care Nurses Association acknowledges the Traditional Custodians of country throughout Australia and their connections to land, sea and community. We pay our respects to elders past and present and extend that respect to all Aboriginal and Torres Strait Islander peoples today.

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