With support from Northern Queensland Primary Health Network (NQPHN), James Cook University has expanded its innovative Social Work in General Practice project, embedding qualified social workers into five GP clinics across Townsville and Cairns.
One of those placements is Ana Munoz, who joined Clements Medical on Magnetic Island in early 2024. Since then, Ana has become a valued and trusted member of both the healthcare team and the wider community.
Life on an island comes with unique challenges, particularly when it comes to accessing health and social services. For many residents, navigating aged care, disability, and support systems such as the National Disability Insurance Scheme (NDIS), Centrelink, and the Department of Veterans’ Affairs (DVA) can feel overwhelming.
Ana’s role has been to bridge that gap – guiding patients and families through processes, advocating on their behalf, and ensuring they can access the services they are entitled to.
“Since starting at Clements Medical, my main goal has been to ensure that patients and families feel supported and connected to the care they need,” Ana said.
“On Magnetic Island, many people face challenges such as social isolation, limited aged care support and transport, and fewer available services in general. Because of this, my focus has been on helping patients to navigate their health, aged care, housing and financial systems, while also providing emotional and psychosocial support during times of stress, illness, or crisis.”
Ana helps manage the complex needs of elderly and vulnerable patients, coordinates emergency respite, and arranges case conferences with multiple providers. She supports patients navigating the My Aged Care process, assists with advanced care planning, and provides additional support to families facing challenging decisions.
“By doing this, I believe I’ve been able to reduce the pressure on patients, carers, and families who might otherwise feel they have to manage everything on their own and not knowing where to start,” she said.
“My holistic and eclectic approach helps them feel less overwhelmed and gives them more space to focus on the management of their medical conditions while staying engaged with their treatment – and as a result, their overall wellbeing improves.”
Patients and families consistently speak of the difference Ana has made to their lives.
“Ana is amazing, she has helped us navigate the paperwork and systems to get access to services for my parents when we were hitting many roadblocks before,” one patient said.
Another shared their gratitude for Ana’s help in their transition to residential care.
“It was a stressful time, and I didn’t know where to start,” the patient said.
“I really appreciated having the time with Ana to understand what carer and support options I had available to me. I really needed that time and she is an amazing resource and wealth of information and support.”
Ana said being embedded directly within the GP clinic makes a profound difference.
“I think we are able to support people in a much more immediate and holistic way compared to other social work roles,” she said.
“Instead of patients having to wait for external referrals or travel to different services, I can connect with them right at the point of care. I work closely with their GP and practice team which reduces barriers to access.
“The GP setting gives us the opportunity to pick up on social and emotional needs early – these are often raised during medical appointments – and we can work closely with the clinical team to address those needs as part of the patient’s overall health plan. It also allows for stronger continuity of care, because patients don’t feel like they’re being ‘handed off’ to a separate system – they experience us working together.”
Doctors and nurses at Clements Medical have described Ana’s contribution as transformative – not only for patients, but also for the practice itself.
“This model embodies the essence of true multidisciplinary primary care which is acceptable, accessible, holistic and patient centred. Where – with Ana’s help and expertise – we can work together to achieve the best possible outcomes,” one practice nurse said.
A GP said Ana was serving the needs of a diverse and high/complex needs rural community.
“Her work is invaluable and exceptional. She takes a huge workload off my shoulders, which directly translates into freeing me up for more patient care,” they said.
Working on an island brings its own unique pressures, and Ana has adapted her approach accordingly.
“One of the biggest challenges of working on an island is the limited access to services and resources,” she said.
“To adapt, I focus on making services as accessible as possible to the community. That includes linking patients with telehealth options if feasible and coordinating with local and mainland providers.
“A key part of this is working in partnership with service providers and specialised organisations, building strong relationships for collaborative work. This offers a wider range of options and choices for patients, which means care can be more flexible and patient focused.”
The Magnetic Island Community Advisory Network (CAN) has been a strong supporter of Ana’s role and the Social Work in General Practice project.
Chair Mal McLean said Ana’s service has been consistently recognised and valued by patients, families, and clinicians alike.
“Ana complements the medical team and helps provide holistic and comprehensive care in a way that simply wasn’t possible before she arrived,” Mr McLean said.
“The community has been overwhelmingly positive about Ana’s work, and we regard this service as exceptional and highly valued.”
Ana’s role also extends beyond immediate patient support. By embedding within the general practice setting, she contributes to student supervision and research that is grounded in practice, building long-term capacity for primary care.
Her presence demonstrates the benefits of a truly integrated care model – one that combines medical and social expertise to achieve better health outcomes.
For patients, clinicians, and the community of Magnetic Island, Ana’s work is more than just support – it represents access, advocacy, and care that acknowledges the whole person.