Practice Nurses (PNs) are at the interface between primary care and hospital services, yet their capacity to improve integrated care has not been fully explored. The Peer Led Collaborative (PLC) group brought together PNs and Clinical Nurse Consultants (CNCs) in the St George locality for small group learning sessions from July to December 2019. It was a project within the NSW Health Integrated Care Strategy aiming to deliver seamless care in the health system.

Project Status

Completed Projects

Chief investigators

Dr Cathy O'Callaghan, Dr Sonia Van Gessel and Assoc/Prof Ben Harris-Roxas

Project coordinator

Dr Cathy O’Callaghan, SEaRCH, UNSW, Dr Sonia Van Gessel, Population and Community Health (PaCH), South Eastern Sydney Local Health District (SESLHD)

Team members

Jan Sadler (CESPHN); Anna McGlynn (Health Pathways); Brendon McDougall, Integrated Care, SESLHD; Sandy Johnston, Integrated Care CNC, SESLHD; Australian Practice Nurse Association (APNA)

Project Rationale

The PLC was a partnership between Central and Eastern Sydney PHN (CESPHN), South Eastern Sydney Local Health District (SESLHD) and South Eastern Sydney Research Collaboration Hub (SEaRCH) at University of New South Wales (UNSW) that brought together health care professionals in the St George locality.

The model built on the learnings of the St George Division of General Practice and CESPHN’s ‘Small Group Learning’ (SGL) program which is an established model of education primarily for General Practitioners. Similar international models demonstrate benefits not only for participants, but also to practices and patients.

The PLC aimed to build relationships and strengthen networks between primary care and the hospital sector and by proxy improve health outcomes aligned with the quadruple aims (reduced costs, patient experience, staff experience and population health) in the long term. The project was an initiative of the Integrated Care strategy in SESLHD.

Project Aim/s

PLC Group Learning Objectives

  • Understand roles of hospital and primary care services
  • Understand how PNs refer patients to the hospital
  • Understand how to access Health Pathways
  • Increase hospital and general practice connectivity

Project Design and Method

Six small group learning sessions were conducted with PNs and CNCs. The topics included:

  • Set learning objectives
  • Accessing Health Pathways information portal
  • Transferring care from primary care to the hospital
  • Communication between hospital and primary care
  • Referring patients to Extended Community Care
  • Future directions


Small group learning can enhance seamless care. However, the broad scope of practice and various learning needs of PNs place constraints on their ability to bridge services. Self-sustaining learning sessions were therefore difficult. Future initiatives could be to map PN needs and locations, provide clinical clustered mentoring and continue networking / learning opportunities.



Dr Cathy O’Callaghan Phone: 0415511177 Email:

Key Partners

SESLHD, CESPHN, Australian Practice Nurse Association (APNA)



Project lead centre
Project stream
Health System Integration and Primary Health Care Development
Project start date
Project end date