Healthcare Transformation​ Research Program

ED ASET Nurse undertaking a Pace-IT telehealth consultation

Our collective purpose is to optimise healthcare experiences and outcomes for individuals, families, communities, and healthcare providers.

Health services are currently fragmented, lacking coordination and integration between providers and across healthcare settings, with insufficient focus on the person at the centre of care.

Different health professions and providers often operate in silos. This results in gaps in care, conflicting advice or treatments, duplication of costly services and waste of precious health care resources. These factors can undermine quality of care and negatively impact experiences and outcomes of care, particularly for priority populations.

Despite there being an abundance of research to inform clinical practice (it is estimated that over 1 million articles are published every year in Pub Med), many patients fail to receive evidence-based care.

This is commonly referred to the evidence/practice or know-do practice gap - a gap that has been estimated to take 17 years to bridge - that is 17 years from knowledge generation to implementation in practice. And when it does, only a modest 14% of that evidence reportedly reaches the patient.

The consequences are that an estimated 30-40% of patients do not currently receive evidence–based care, and 20-25% of care currently delivered is deemed unnecessary and potentially harmful.

In response, we have adopted a whole of system approach rather than focusing on one disease or condition to undertake transformative, person-centred, practice-based research - research that is targeted toward diverse healthcare needs across the lifespan. Research undertaken within our program crosses jurisdictions, disciplines, and geographic boundaries.

Our philosophical approach is first and foremost transdisciplinary. We value the diversity of knowledge (from healthcare consumers, healthcare providers, service managers, academic researchers, and policy makers) to co-create innovative solutions, solutions that can be translated into practice, and that will drive health services transformation.

Such an approach will lead to new clinical, academic and industry partnerships, integrated models of care, and ultimately more timely and effective care than that being provided by current health services.

Our program is equally committed to building research capability within the healthcare workforce.

Aspiring clinician researchers within our program can access opportunities to build research skills and capabilities, access small “seeding” grants to progress their own practice-based research projects, access career mentoring, and collaborate with academic and other researchers to work on impactful, patient-centred, and cost-effective solutions to “real-world” clinical challenges.

Innovation & Discovery

Our research covers a range of diverse healthcare needs and priority populations. These include maternal and infant health, pain, drug and alcohol, mental health, and older person care.

All projects supported in our program arise from clinical practice, with clinician-driven research more likely to align with the priorities of the health service, and far more likely to be implemented or translated into practice.

The PACE-IT Project

Partnership In Aged Care Emergency with Integrated Technology 

Transfer of people who are residents of residential aged care facilities (RACF) to emergency departments (ED) is common, risky and expensive. Up to 44% of transfers are considered unnecessary and can expose residents to additional investigations and treatments. This can cause additional harm through emotional stress and iatrogenic (illness caused by medical examination or treatment) complications, rather than enhance care.  

The PACE-IT project is an interactive visual telehealth assessment and clinical decision-making model of care (MOC) that is not yet used anywhere in Australia. 

We implemented and evaluated whether the combination of MOC and enhancement of the well-established nurse-led telephone-based aged care emergency (ACE) led to improved communication, ensured the right care was delivered in the right place in a timely way, reduced emergency department (ED) transfers and provided a more integrated and person-centred approach to care for the older resident. 

Our research found a 53% uptake of the PACE-IT model of care and a clinically significant 29% reduction in emergency department (ED) presentations. The initiative is now embedded in routine aged care emergency practices and a reduction in the number of unnecessary ED transfers is the result. 

Resident and staff from RACF taking part in a PACE-IT telehealth consultation with an ED ASET Nurse

PACE-IT Awards

  • Winner of the 2021 HNELHD Integrated Value Based Care Quality Award
  • Current finalist in the 2021 NSW Health Secretary’s Award for Integrated Value Based Care

PACE-IT Publications to date

Tapering and ceasing prescription opioids in chronic non-cancer pain

This research will utilise expertise from patients, specialist clinicians and researchers to develop a healthcare intervention that supports people with chronic non-cancer pain to safely transition from long-term prescription opioids to non-pharmacological pain management strategies.

Current evidence suggests that coming off opioids improves treatment outcomes for patients attending specialist pain services. But the logistics of coordinating the specialist multidisciplinary health services needed to support patients to reduce opioids, particularly in the absence of accessible and effective treatment alternatives, can be a barrier to success. 

Our research is much needed, as more than 70% of all opioid-related overdoses involve prescription opioids and accounts for 14 emergency department admissions and three deaths per day.

Embedding Nurse Practitioners in rural and remote emergency departments

Rural and remote emergency departments collectively manage one third of all Australian emergency department presentations yet remain chronically understaffed.

Outreach medical services go some way to improving access to emergency care in rural and remote regions, but these often result in delays in care for those presenting with life-threatening conditions or costly inter-hospital transfers for patients with less critical conditions.

Without adequate access to timely quality emergency care services, people die from avoidable deaths and these avoidable death rates are proportionally higher in rural and remote areas.

Nurse practitioners are registered nurses, educated at Masters level, who diagnose and treat a range of health conditions, can order and interpret tests, and prescribe necessary and appropriate medications working collaboratively with other health practitioners.

This project will assess the effectiveness of embedding a Nurse Practitioner model of care focused on providing safe, equitable and timely service to rural and remote communities accessing emergency care. It is a highly feasible and cost-effective solution that has been shown to be effective in metropolitan settings.

EMDR interventions in a public drug and alcohol service

Approximately 80% of Australians seeking treatment from alcohol and other drug (AOD) services report experiencing trauma, and up to two-thirds have post-traumatic stress disorder.

Eye Movement Desensitisation and Reprocessing (EMDR) has an evidence-base in for trauma resolution in general populations.

Evidence exists for its ability to decrease cravings, fears, and depression in those experiencing AOD problems however, a literature gap regarding its implementation and effectiveness exists, particularly in outpatient AOD services.

The project will generate new knowledge by evaluating the implementation of EMDR in a local health district drug and alcohol service, including its acceptability among EMDR-trained clinicians and AOD clients.

Management of UTIs, Oral Contraception & Skin Conditions by Community Pharmacists

Program Member – Dr Sarah Dineen-Griffin (Project Lead, University of Newcastle’s School of Biomedical Sciences and Pharmacy)

Prior Australian research has demonstrated that community pharmacists in consultation with general practitioners, can provide clinically and cost-effective management of minor ailments, compared to usual care.4 Moreover, a recent systematic review found that pharmacist management of minor ailments is associated with low re-consultation and high clinical cure rates.1

The focus of this major state-wide trial, supported by $6million in funding from NSW Health, is on community pharmacists managing urinary tract infections, oral contraception, and some skin conditions.

The project involves a consortium of 18 partner organisations including HMRI, the Royal Australian College of General Practitioners and the NSW Rural Doctors Network. Project stakeholders include general practitioners (GPs), infectious disease clinicians, pharmacists, rural clinicians, and Aboriginal and Torres Strait Islander people.

Key elements of the trial include:

  • clinical preparation of pharmacists through an accredited program, as well as follow-up training and ongoing support.
  • co-designed best practice guidelines for pharmacist management of the agreed minor ailments.
  • timely referral to GPs or emergency departments if ‘red flag’ symptoms present.
  • consultation notes recorded on dedicated software.
  • use of a referral and communication system with GPs that was agreed during the co-design process.
  • patient follow-up after one week, with reporting of adverse events.

Ultimately, the project will strengthen and transform primary health care, ensuring collaboration, and that patients receive safe, appropriate, and timely access to treatment.

You can read more about the trial here.

Funding: NSW Health

  1. Dineen-Griffin, S., Benrimoj, S. I., Rogers, K., Williams, K. A., & Garcia-Cardenas, V. (2020). Cluster randomised controlled trial evaluating the clinical and humanistic impact of a pharmacist-led minor ailment service. BMJ quality & safety, 29(11), 921–931.
  2. Dineen-Griffin, S., Vargas, C., Williams, K.A. et al. (2020). Cost utility of a pharmacist-led minor ailment service compared with usual pharmacist care. Cost Eff Resour Alloc 18, 24.
  3. Dineen-Griffin, S., Benrimoj, S.I., Williams, K.A. et al. Co-design and feasibility of a pharmacist-led minor ailment service. BMC Health Serv Res 21, 80 (2021).
  4. Dineen-Griffin, S., Benrimoj, S. I., Rogers, K., Williams, K. A., & Garcia-Cardenas, V. (2019). An Australian minor ailment scheme. Evaluation of an integrated approach by community pharmacists and general medical practitioners. Report.
All Inclusive Care for Older People (ALICE): A Neighbourhood Model of Care for the Central Coast Community​

Program Members – Prof Nick Goodwin (Chief Investigator), Cate Dingelstad, and Dr Zoi Triandafilidis (Central Coast Research Institute).

The Central Coast is home to the largest and fastest growing number of people who are frail in New South Wales. This cohort are at the highest risk of adverse outcomes such as falls, disability, unscheduled hospital admissions, longer stays in hospital, uncontrolled polypharmacy, and greater difficulty recovering from illness and surgery.

There is a pressing need for improved engagement in prevention and health promotion activities that support older people to live as well as possible in their home environment. However, the lack of coordinated access to primary and community-based services and aged care support (some 35% of people do not have access to a GP on the Coast), combined with increasing numbers of older people living in social isolation, means that care outcomes are not optimal.

To address this, the ALICE (All Inclusive Care for Older People) project, aims to support people to remain independent and well, and to avoid the need for hospital visits or residential care.

We will be working with local communities to create local models of services and community connections that allow older people and their carers to receive support and best-practice care in the community and at home.

ALICE is designed to build on the Central Coast’s Elderly and Frail Connected Care Pathway approach to create an evidence-based neighbourhood model for integrated community care.

More details can be found here.

Using co-design to improve care experiences and outcomes for people and carers living with dementia at the end of life​

Program Members – Prof Nick Goodwin (Chief Investigator), Cate Dingelstad, and Dr Zoi Triandafilidis (Central Coast Research Institute).

In February 2023, the Central Coast Research Institute (CCRI), HammondCare and the Central Coast Local Health District (CCLHD) initiated a co-design process across key stakeholders focusing on integrated models of care that improve care experiences, outcomes and effectiveness of services delivered with and for people living with dementia at the end-of-life.

This co-design initiative was borne of ongoing discussions about the need to significantly improve the end-of-life care experience for people living with dementia on the Central Coast, including consideration of the research findings from a 3-year project undertaken by the CCRI and CCLHD that identified the key attributes to such a model.

The co-design group was keen to take stock of the many existing resources, programs and toolkits that exist in the dementia and palliative care space – as well as to focus on different aspects across the ‘dementia and palliative care’ journey where improvements in care could and should be developed.

The partners have committed to undertake four facilitated half-day co-design workshops to develop a value case for an improved model of care for people living with dementia and carers at the end- of-life for testing out during a workshop with an international audience at the 3rd Asia Pacific Conference on integrated Care (APIC3) to be held in November 2023. In addition, the co-design activities will be developed as a case study as part of a NSW Regional Health Partners initiative to develop a roadmap and resources to help guide and inform how to undertake co-design initiatives that support research and research translation.

Funding: HMRI Healthcare Transformation Research Program Seed Funding - 2023

Pilot Feasibility & Validation Study: Harmful and Ineffective Hospital Patient Healthcare can be detected early by Patient's Digital Auscultation Monitoring (DAM) + Health Informatics System (HIS)​

Program Member/Chief Investigator – Conjoint A/Prof Gary Baker (Armidale Rural Referral Hospital)

Adverse and/or ineffective treatments are still common for Hospital patients. This is occurring despite decades of using mandated Deteriorating Patient Safety Net Clinical Systems for recognition, response, and management of the acute physiological deterioration of patients.

Typically, standard vital sign observations are taken regularly to monitor clinical status, which intensifies if there is a persistent trend of deterioration, but often too late.

An alternate Clinical approach is to assume that all treatments are harmful or ineffective until physiological monitoring demonstrates improvement.

Continuous physiological monitoring commences automatically on admission and decreases once the appropriate healthcare is provided. Monitoring may identify chronic pathophysiological conditions, which also need treatment, before any physiological improvement occurs.

Patient Digital Health Learning Informatics Systems incorporating the non-invasive physiological monitoring with artificial Intelligence processing may be the tool that enables this Clinical approach.

The Sonomat is a mattress that contains a series of vibroacoustic sensors that can identify body movements, breathing movements, respiratory, heart and gastrointestinal system sounds.

The use of advanced signal processing and machine learning to characterise both the stable physiological state, changes that predict clinical decompensation, and those of improvement will enable the development of intelligent systems (and protocols) to alert and assist the clinician in clinical decision making and patient management. This device has previously been validated (TGA approved) for the diagnosis of sleep disordered breathing.

This pilot study will investigate the feasibility of re-purposing of the Sonomat device for continuous physiological monitoring, aiming to demonstrate its utility in capturing clinical observation data equivalent to standard adult general observations (SAGO), as well as identifying significant clinical conditions not detected with SAGO or prior to hospital admission.

Two groups of patients (≥ 60 - 80 years of age; equal numbers of female and male patients) will be recruited to the study. The first group will be those who are scheduled to undergo total knee replacement, total hip replacement or fractured neck of femur surgery at Armidale Rural Referral Hospital; the second group will be from admissions from the Emergency Department to the High Care unit at the same hospital. Statistical analyses will evaluate agreement between the clinical state endpoints measured using Sonomat and SAGO. Additionally, the physiological/pathophysiological data generated will be used to develop complex models that have the potential to predict adverse pathogenesis states, clinical improvement, and homeostasis. Ultimately, the project has the potential to catalyse the transformational shift to Precision Medicine.

Funding: HMRI Healthcare Transformation Research Program Seed Funding - 2023

Nurse-led follow up phone calls for patients discharged from acute care facilities: A mixed method process evaluation of the uptake and impact

Program Members – A/Prof Michelle Giles (Chief Investigator), Gena Lieschke and Maralyn Foureur (Hunter New England Health District’s Nursing & Midwifery Research Centre)

Patients are being discharged from hospital earlier, requiring complex post discharge instructions. Therefore, the transition of care from hospital to home may be a particularly vulnerable time for patients and could lead to post-discharge adverse events and readmissions.

In NSW Health, approximately 19% of admitted patients do not understand explanations from health professionals, 34% do not feel involved in discharge decisions, and 27% feel they do not receive enough information to manage their care at home.

A follow-up phone call (FUPC) refers to a call made by a clinician (doctor, nurse, midwife, or allied health professional) to all eligible inpatients the day after discharge.

The anticipated short-term outcomes of FUPCs in the Hunter New England Health District (HNELHD) are threefold: to verify that patients have received and understood their discharge summary with care instructions; to determine patient compliance with care instructions; and to address any concerns regarding the patient experience or new symptoms that may halt the recovery process.

This study aims to evaluate FUPCs to better understand current practices and processes and inform intervention refinement across variable contexts within HNELHD.

The RE-AIM theoretical framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance) will guide a mixed methods evaluation. Quantitative and text data will be obtained from historical service data and via an online survey of key stakeholder groups with responsibility for FUPCs (nursing and midwifery managers and clinicians). Qualitative data will be collected via focus groups with purposively recruited inpatient, ward-based nursing and midwifery clinicians and unit managers, via an online or telephone questionnaire with patients who have previously received a FUPC post hospital discharge. Findings will assist in refining current procedures to further optimise the inpatients care transition from hospital to the home.

Funding: HMRI Healthcare Transformation Research Program Seed Funding - 2023

Resilience and Retention (An exploratory story of workplace factors supporting Australian and Overseas Trained Nurses)

Program Members – A/Prof Brendan Boyle (Chief Investigator, University of Newcastle’s Health Services Research and Workforce Innovation Centre), A/Prof Michelle Giles and Dr Gena Lieschke (Hunter New England Local Health District’s Nursing & Midwifery Research Centre) and Prof Nick Goodwin (Central Coast Research Institute).

Understanding the factors that contribute to mental health challenges at work is vital given their devastating personal and economic impact. Research indicates that this is significant for nurses and midwives as their organisational environment includes stressors that contribute to psychological distress.

Resilience, the ability to ‘bounce back’ or recover from adverse or stressful events, decreases the negative impact of workplace stressors, and is associated with increased quality of life, improved health, and workforce retention.

Research has, however, primarily focused on individual resilience and interventions. For this reason, there remains little understanding of the work-related factors (organisational interventions) that contribute to or undermine resilience and retention.

This project will uniquely explore the topic of resilience through a dual lens – focusing on both Australian-born nurses and midwives, while also accounting for additional workplace stressors for overseas trained health professionals/nurses and midwives (OTHPs). This is an important consideration as recruitment and retention of overseas trained nurses and midwives is a pressing issue in Australia, particularly in rural regional centres.

Interviews will be conducted with nurses and midwives both from John Hunter and Tamworth Hospitals to identify stressors that impact on mental health and the factors that support resilience and assess the extent to which work-related factors are perceived to lessen the negative impact of stressors.

The impact of training and support on the resilience for OTHPs and how these impact on the retention will also be evaluated. Following the conduct of the first phase of the study, additional funding will be sought to conduct a broader, more detailed 20-minute survey that is informed by interview data. Drawing on the study findings, the researchers will work with employers to develop guidelines for the design of work and workplaces to build employee resilience.

Funding: HMRI Healthcare Transformation Research Program Seed Funding – 2023

SLAM-B: Self-administration of Bortezomib for patients with myeloma: A pilot study

Program Member/Investigator: Prof Nick Goodwin (Director Central Coast Research Institute).
Project Lead: Jacqui Jagger, Haematology Nurse Practitioner, Cancer Services, Central Coast LHD

Multiple myeloma (MM) is an incurable cancer of plasma cells. One principal treatment regimen includes weekly or twice weekly chemotherapy injections administered at specialist cancer day units (CDU).

This project was instigated after routine MM patient experience surveys and direct patient reporting identified the highest area of unmet need was related to the frequency and length of hospital attendance, and the additional cost and burden associated with numerous appointments.

This pilot project examines the feasibility, safety, and acceptability of a new model for eligible myeloma patients using self-administration of subcutaneous Bortezomib (chemotherapy) in the home setting. Using a prospective mixed method design, patients (or carers) will receive a period of training and complete a competency assessment prior to sign-off as eligible for the home program.

Day 1 of each treatment cycle is delivered in the CDU allowing monitoring of the injection technique, delivery of any intravenous components and to collect medications. Subsequent subcutaneous injections for the cycle will be administered at home by the patient (or carer). Prior to each injection, patients (or carers) will receive a telehealth assessment from a trained chemotherapy nurse.

To evaluate the model of care, patient (or carer) experience will be explored using a pre and post Self-Injection Assessment Questionnaire (SIAQ), a patient experience survey and patient stories.

Safety and efficacy data will be collected using pathology results, reported adverse events and a symptoms and concerns scale (FACT-GOG-NTX-13). Staff experience and acceptability of the model of care will be explored using focus groups.

A cost evaluation supported by HMRI will compare the average cost of an injection of Bortezomib in the outpatient unit of the Department of Haematology and at home. Time burden data will be collected including number of visits, if accompanied by carer, time to get to the visit, distance to get to the visit, time spent at the visit.

Funding: NSW Regional Cancer Research Network


HMRI Healthcare Transformation Research Program Team 

Executive Leadership Committee
Operations Leadership Comittee



Simone Perry
Research Program :
  • Healthcare Transformation​ Research Program
Research Topics :
Effective Health Services, Global Health, Healthy Ageing, Psychology
Dr Zoi Triandafilidis
Research Program :
  • Healthcare Transformation​ Research Program
Research Topics :
  • 1
  • 2