Population Health

Improving population health contributes to the wellbeing of communities across our State.

Population health describes the range of activities we undertake that contribute to the wellbeing of communities across our State, including improving chronic disease early intervention and management, immunisation and cancer screening.

Funding services to support people with chronic conditions that keeps them well and out of hospital and supporting general practices with current information on immunisation and cancer screening programs helps to deliver better health, together.

Our Priorities

  • Improving the management of chronic disease in primary care and reducing rates of potentially preventable hospitalisations by working with primary care providers to target high quality health care for priority populations.
  • Increasing childhood immunisation rates within regions not meeting national immunisation targets.
  • Increasing influenza immunisation rates, particularly for older adults.
  • Increasing access to cancer screening programs, by working with general practice and other stakeholders.

Key Activities

Integrated Chronic Disease Care: A service that provides country-based clients access to clinician treatment services and supports them to maintain independence, self-manage their condition and, most importantly, improve their health and wellbeing.

Healthy Weight GP Project: Part of the WA Healthy Weight Action Plan 2019-2024, a joint initiative of WA Health, WA Primary Health Alliance, and Health Consumers' Council. The project will provide an online Healthy Weight ‘hub’, housing tools and resources to support GPs and practice staff to identify patients who are above a healthy weight range, refer patients to appropriate weight management services or programs and provide support and motivation.

Chronic Heart Failure: Targets specific areas with higher than average rates of chronic heart failure and engages primary care and hospitals to improve care for people living with chronic heart failure through transitions of care, care coordination and service linkages. This includes facilitating a multidisciplinary heart failure team, trialling models to strengthen integrated care for chronic heart failure and developing workforce capacity to be effective partners in a multidisciplinary model of care.

South West Chronic Conditions Collaborative: A multi-agency group focused on increasing self-management, improving health outcomes and preventing avoidable hospitalisations among people with chronic conditions, with a particular focus on chronic heart failure, chronic obstructive pulmonary disease, diabetes and renal disease.

COVID-19 Respiratory Clinics: In response to COVID-19, WA Primary Health Alliance worked with the Australian Government Department of Health to establish GP-led respiratory clinics across Western Australia to assess and treat people with mild to moderate respiratory conditions, including testing for COVID-19. This is part of a national initiative, with about 150 Respiratory Clinics across Australia.

Key Achievements

  • Led the establishment of 12 GP respiratory clinics across Western Australia in response to COVID-19.
  • Supported general practice to address weight management with patients through reviewing available resources and identifying barriers, enablers and gaps to engage with patients in weight identification and intervention.
  • Commenced developing an online resource and education hub to support general practice with weight management identification and intervention.
  • Partnered with the Australian Practice Nurses Association to support six general practices to establish a chronic heart failure nurse clinic in targeted areas of Western Australia.
  • Selected to join the Health Round Table and Integrated Care Improvement Group in April 2020 and invited to showcase the South West Chronic Conditions Collaborative’s work at a virtual online event, including the pilot below.
  • Contributed to the Western Australian Women’s Health and Wellbeing Policy, a strategic, coordinated and gender-responsive approach to optimise the health, safety and wellbeing of women and girls in WA.
  • Partnered with  WA Country Health Service to provide targeted care and support to vulnerable patients at an increased risk of complications due to COVID-19. Read our case study.
  • Sustained success demonstrated in hospital data with reduced emergency department attendances, reduced length of stay and reduced inpatient admissions for a target cohort of people with two chronic conditions, as part of a joint pilot with WA Country Health Service to develop a better model of care for people admitted to Bunbury Hospital. The graph below tracks progress among a cohort of 220 patients over 24 months, which led to cost avoidance of more than $1.5 million.

Improvements in acute care episodes among people with chronic conditions in the South West

24 months and 220 patients

ED Attendances (154)


Inpatient Episodes (143)


Bed days (>800 saved)


Length of stay


Inpatient Service Improvements

Case Study

Our Priorities

Read about this year’s achievements and the great work being done with our key partners and the community to deliver better health, together.

Aboriginal Health

Improving the health of Aboriginal Western Australians is a critical concern.

View Aboriginal Health

Aged Care

We are committed to increasing access for older Western Australians to primary healthcare.

View Aged Care

Alcohol and Other Drugs

Our focus is on providing services that respond to people as a whole.

View Alcohol and Other Drugs

Digital Health

Digital health helps us to identify priorities, link services, and fund options for better primary care.

View Digital Health

Health Workforce

We build the capacity and capability ofthe primary healthcare workforce to help more people access the care they need.

View Health Workforce

Mental Health

We know that mental ill health is one the biggest health challenges forWestern Australians.

View Mental Health

Population Health

Improving population health contributes to the wellbeing of communities across our State.

View Population Health