OPERATIONAL AND FLEXIBLE FUNDING - HealthyGC · PDF file• Majority of allied health providers trained in RecordPoint • Strategy for Aged Care component developed . October –

Level 1, 14 Edgewater Court, Robina 4226 | PO Box 3576 Robina Town Centre QLD 4230 P: 07 5635 2455 | F: 07 5635 2466 | E: [email protected] | www.healthygc.com.au

Gold Coast Primary Health Network gratefully acknowledges the financial and other support from the Australian Government Department of Health. Primary Care Gold Coast Limited (ABN 47152953092), trading as the Gold Coast Primary Health Network.

OPERATIONAL AND FLEXIBLE FUNDING

[PERSISTENT PAIN PROGRAM] STRATEGIC GOAL Link to PHN Objectives

ACTIVITY NAME Turning Pain into Gain ( Self-Management Persistent Pain Program) 1,2 IDENTIFIED NEED

A large number of patients within the Gold Coast referred to Specialist Outpatients with Chronic Persistent Pain are unlikely to benefit from surgical intervention. A multidisciplinary clinician group identified the need for access to a self-management program for patients diagnosed with persistent pain to assist them in learning to live with their pain, and to relieve pressure on the GCHHS specialty services.

STRATEGY

Provision of a community based persistent pain program providing patient assessment, self-management strategies, access to additional allied health where required.

DURATION 1 July 2015 -30 June 2016 RESOURCING $155,961 Description

The aim of the Persistent pain service is to identify and support self-management strategies that improve care of patients with persistent pain. Service Components include: • Turning Pain into Gain patient self-management education program (monthly) • Activity based workshops to support self-management in a practical application. • Individual patient assessment including identification of health care needs, support to navigate to

appropriate service providers and recommendations to the patient’s GP. • Advanced allied health services (based on revised eligibility criteria) • Allied health and general practice education. • One Day Refresher workshops at 6 months, 9 months and 12 months post program. • Case conferencing between allied health and GP • Evaluation using validated tools for improvement of Quality of Life in partnership with Griffith University

Type of activity

Maintain/enhance existing services, Workforce Support, Education and Information, Consumer Capacity Building (Self-management)

Region

Whole of PHN

Sector

Primary Care sector including GPs and Allied Health, Consumers with Persistent Pain



Service Provision Purchased Services; Joyce McSwan will provide “Turning Pain into Gain” and 22 Allied Health providers will be contracted to provide additional allied health services as required by individuals

Performance information Include headline indicator (% immunised, % reduction in preventable admissions) and applicable process indictors

3. % reduction in potentially avoidable hospital admissions. 5 % of patients managing their own health and wellbeing 8 % of key stakeholders that value PHN engagement

Expected outcome • Patients better able to manage their own health and wellbeing • Increase referrals to Turning Pain into Gain program • Improved outcomes for patients including patient experience and quality of life. • Increase knowledge and education of GPs and Allied Health Professional in chronic pain management. • Reduction in emergency department presentations for persistent pain • Reduction in hospital admissions for persistent pain • Number of patients access follow up program (target 75) • Number of patients accessing pain program (target 150).

Milestones Detailed below is the Persistent Pain Program Schedule for 2015/16 The program will commence on 1 July and run throughout the 2015/15 financial year Access to individual action planning and additional allied health will be available to all participants as required throughout the year. Three persistent pain programs will be run monthly across three locations across the Gold Coast Education Program One Program registration July 15 Education Sessions August 15 – Jan 16 Education Program Two Program registration August 15 Education Sessions Sept 15 – Feb 16 Education Program Three Program registration Sept 15 Education Sessions Oct 15 – Mar 16 Three refresher workshops will be delivered throughout the year for participants of the 14/15 program



[GOLD COAST INTEGRATED CARE] STRATEGIC GOAL

Link to PHN Objectives ACTIVITY NAME Gold Coast Integrated Care 1,2 IDENTIFIED NEED

Gold Coast has a number identifiable needs that have led to the development and approval of the business case for a implementation

of the integrated model of care between the hospital and general practice focusing on those and high and complex needs. The significant areas of need which led to this service design where:

Hospital Admissions Gold Coast region has a higher rate of potentially avoidable admissions than the average for the Metro 2* cohort

of Medicare Locals in Australia with 2,604 admissions per 100,000 people (age standardised) compared to 2,552 for Metro 2.

Inpatient admissions within public hospitals in the Gold Coast Hospital and Health Service are projected to increase by over 50 per

cent between 2011/12 and 2016/17. Specialties with both a high number of admissions and a high projected growth rate include Cardiology, Non Subspecialty Medicine and Respiratory Medicine; all projected to have annual growth rates of

over 10 per cent.

Emergency Department Attendances - ED attends have trended upwards consistently for the last ten years. The number of

attendances increased by 15% last year and 14% in 2012. 2014 has already shown predictions of growth above 15%.

Changing Trends in General Practice Service Delivery – General Practice is managing increasingly complex patients. A survey

undertaken by Bettering the Evaluation and Care in Health (BEACH) in 2005, of 9,156 GP patients found that 3 per cent of patients

had five or more chronic conditions, with 11.6 per cent of patients having three or four chronic conditions. Although primary care

offers enormous potential to better manage prevention, health promotion, chronic and complex care more cost effectively, it cannot

do this without rapid, reliable and timely support from specialist services, and more efficient coordination of community resources to



maintain patients' health and avoid adverse exacerbation.

Ageing Population. By 2036 the number of people aged 65 and over will double, and the number aged 85 and over will triple This will

significantly increase prevalence of dementia and chronic disease, increasing demand on hospital services. Obesity is a significant risk factor for diabetes, cardiovascular disease and some cancers. 64% of region’s adults are overweight or obese compared to Metro 2 - 62%) Socioeconomic inequalities in the Region will present challenges to providing equitable access to quality health

services. A new, more sustainable, integrated delivery model, particularly for chronic disease, is required to respond to these challenges in the future.

STRATEGY

Gold Coast Integrated care (GCIC) model delivered primarily in the primary care sector involving the holistic management of patients with complex and comorbid conditions Proof of concept to be implemented over a 3 year period with funding from Queensland Health and The Department.

DURATION 1 July 2014- December 2018 is the proof of concept phase Description

The PHN will continue to work in partnership with the Gold Coast Hospital and Health Service to work with identified General Practices, Allied Health, Community Organisations and Residential Aged Care Facilities. This patient centred model brings together multidisciplinary teams to provide holistic care to patients through a single shared plan of care. The service continues to target high risk patients such as the aged and those with chronic, complex and comorbid conditions such as diabetes, chronic obstructive pulmonary disease, renal and cardiac disease The model includes:

• Data mapping to identify patients utilising both HHS and General Practice service and determine those patients who will benefit most from referral to the model

• Risk stratification to identify patients most at risk • Holistic assessment process to develop a single shared plan of care identifying goals and actions aimed at

minimising duplication of services and maximising coordination of care • Provision of service navigators including access to an online service directory to assist patients and their

families to better navigate the health care system • Rapid access to services, for identified patients, during periods of exacerbation to continue to manage

patients care in the community



• Coordination of change management, education, training and support programs for; o General practices and allied health; o Residential and community care sector; and o Patients and their families.

The model aims to: • Decrease avoidable hospital presentations/admissions • Improve patient outcomes • Improve patient satisfaction • Improve support and capability to GPs and the wider primary care providers in managing patients with

complex and comorbid conditions • Improve communication between healthcare providers by utilising an electronic information

management system to house the shared plan of care and enable sharing of relevant summary data between the HHS, GPs, Allied Health providers and Community service providers

Type of activity

Workforce , Integration and Coordination of services enhance existing services education and training

Region Gold Coast Region Sector

Patients with high and complex health need at high risk of hospitalisation, GCHSS Medical specialists and multidisciplinary team, General Practice, Allied Health, Community and Residential Aged Care Facilities

Service Provision

Collaborative model with PHN and GCHHS contributing capacity and resources to the program. Purchased : Service Navigator Role through Gold Coast Health and hospital Service Afterhours medical and support services

Performance information

3.% reduction in potentially avoidable hospital admissions. 4. % increase in access to services for targeted groups. 6. % of patients with a reduction in specified clinical indicators. 7. % of primary health staff that have enhanced their skills and knowledge. 8. % of key stakeholders that value GCML engagement

Expected outcome • Increase in primary health care utilisation • Improved patient outcomes • Reduction in secondary care utilisation

o Emergency department attendances o Emergency department admissions o New outpatient utilisation



o Review outpatient utilisation o Decrease in average length of stay.

• Increase patient experience and satisfaction • Increase clinician experiences and satisfaction • Improved data sharing and analysis across primary and secondary health care providers

Milestones July On board General Practice & Community Allied Health ICT tool installed and training for system completed in each in scope practice Data mapping and risk stratification completed for in scope practices Practice Support –

• Data system supported for timely reporting ,and review quarterly • Training in ICT systems • Final practice on-boarded

August – September • Complete holistic assessments on the majority of Category One patients • Complete training of all practices in RecordPoint • Majority of allied health providers trained in RecordPoint • Strategy for Aged Care component developed

October – November • Categories 2 & 3 patients identified and relevant documentation completed • Population data collection underway

December 2015 • Holistic Assessment process completed for core identified patients • All core identified patients enrolled in program

[GPLO] STRATEGIC GOAL

Link to PHN Objectives ACTIVITY NAME GP Liaison Officer 1, 2, 3 IDENTIFIED NEED

Support for General Practice is a requirement of The Department’s funding agreement and has been a long standing function to support and assist to adopt best practice methods for General Practitioners and General Practice to maximize both its business and clinical practice to improve performance and quality of care. The



effective transition of patient information between primary and acute services is consistently assessed as requiring significant improvement in timeliness and quality by general practitioners. Poor transition of care contributes to potentially preventable admissions to hospital. Avoidable hospital admissions region has a higher rate of potentially avoidable admissions than the average for the Metro 2 cohort of Medicare Locals in Australia with 2,604 admissions per 100,000 people (age standardised) compared to 2,552 for Metro 2.

STRATEGY

To support the transition of care for patients between primary and acute care through more effective referral and discharge planning systems.

DURATION 1 July 2015 – 30 June 2016 Description

General Practice Liaison Officer (GPLO) who is primarily based in the Gold Coast Health implements an annual plan of activities specifically targeted at facilitating improved co-ordination and integration between the GCH and primary Care. This team will lead work: • Provision of targeted education by Hospital Specialist for General Practitioners • Improving transfer of care between GCHHS and GP’s including improving performance in discharge letter and

summaries • Managing electronic referral templates and service directories to develop referral pathways for streamlined

and efficient access to specialist outpatients and hospital community services • Providing specialist general practice input into GCH internal improvement activities and working groups which

will involve; o Reducing outpatient waitlist o Transfer of Care

• Assisting in ensuring GP information is up to date and accessible to GCH Type of activity Workforce support, Maintain and enhance existing services, Education and training Region Gold Coast Region Sector General Practice, Allied Health, Community and Residential Aged Care Facilities Service Provision Delivered directly by PHN : Practice Support Performance information Include headline indicator (% immunised, % reduction in preventable admissions) and applicable process indictors

• reduction in potentially avoidable hospital admissions. • % of primary health staff that have enhanced their skills and knowledge.

• % of key stakeholders that value GCML engagement



Expected outcome • Improved use of e-health communication between General practice and HHS

o Increase in number electronic discharges to GP within 48 hours of discharge. o Improved quality of GP referrals to Specialist Outpatients o Timely general practice access to hospital pathology and radiology results

Milestones July • Reassess current GPLO activities and agree new schedule of work with GCHHS August

• Provide practice support for referral as required • Commence practice support training program to staff

September • Commence operational plan against identified KPI’s

October onwards • Implementation of above and ongoing activity

[IMMUNISATIONS] STRATEGIC GOAL

Link to PHN Objectives ACTIVITY NAME Childhood Immunisation 1,2,3 IDENTIFIED NEED The QLD immunisation target for this age group is 95%- 5% higher than the national target. With the Gold Coast’s

transient population and high numbers of conscientious objectors, this a challenging task. On the Gold Coast we have retained a rate of at least 89% over the past decade despite these factors and an increasing denominator of eligible children aged 0-7 years.

The National Health Performance Authority report Healthy Communities – Immunisation rates for children 2012-13, indicates that in 2012 the immunisation rate for Gold Coast girls to protect against HPV (human papillomavirus) was one of the lowest in Australia. Specifically, the Gold Coast HPV immunisation rate for girls turning 15 in 2012 was 60 per cent compared with the national average at 70 per cent

STRATEGY Development and implementation of a Gold Coast Immunisation Strategic and Operational Plan to increase immunisation rates

DURATION 1 July 15 to 30 June 2016 Description

Partnership & Collaboration PCGC will partners with the Gold Coast Health and Hospital Service Public Health Unit to:



• Develop and implement a Gold Coast Immunisation Strategic plan • Convene joint forums for health professionals and Public Health unit • Develop strategies to ensure continuity of service to the community due to the cessation of City of Gold Coast

(Council) immunization clinics Early Childhood Immunisation program Target Population 0-7 years Service Components will include; • Practice Support

o Telephone o Face to face o Resources

• Quarterly performance reporting to practices • Education programs ( for health professionals)

o Back to Basics x 6 sessions o Catch up schedule x 4 sessions

• Engagement and collaborative working with local Immunisation activities including Public Health Unit, school based programs, Close the Gap and community activities

• Analysis and reporting on immunisation data in partnership with Queensland Health • Engagement with aged care facility and Child care Centres

School Immunisation Program Target population Year 8 male and female students Work with the GCHHS PHU to implement The School Immunisation program. Service Components will include; • Marketing and general practice support through:

o HPV posters o Data cleaning recording and reporting

• Website promotion on Healthy GC and editorial/radio interviews • General practice engagement

Type of activity Education & Information, Workforce Support. Early Intervention, maintain enhance existing services Region Whole of PHN Sector Early Years, GPs, Nurses and general practices, Education (High School), Gold Coast Hospital and Health Public

Health Unit Service Provision Delivered directly by PHN : Practice Support



Performance information Include headline indicator

PCGC Key Performance Indicators 2 % Increase in immunisation rates (for 0-7 & HPV.) 7. % of primary health staff that have enhanced their skills and knowledge. 8. % of key stakeholders that value GCML engagement

Expected outcome Maintain and improve vaccination rates to >90% for 0-7 and improve above 60% for school based

• number of primary health care staff that have undertaken further training in immunisation • increase capacity of the Child care workforce to promote childhood vaccinations

Milestones • 30 June 15 • Completion detailed project plan for implementation July 2015-June 2016 – • Continuous practice support and provision of resources • Commence early year and school based immunisation programs • Completion and implementation of Gold Coast Immunisation Strategic Plan • Commence bimonthly training sessions of B2Basics Training & Catch-Up Training

[HOMELESSNESS] STRATEGIC GOAL

Link to PHN Objectives ACTIVITY NAME Surfers Paradise Anglican Crisis Care (SPACC) - Homelessness 1 IDENTIFIED NEED Socioeconomic disadvantage, Homeless (at risk of homelessness) clients, poor access to health and social services. STRATEGY

Social Work Student Hub with students of Griffith & Southern Cross Universities providing crisis management, case management, advocacy, assessment & referral and Group Programs to homeless people at St Johns Drop In Centre in Surfers Paradise. Podiatry services delivered by students of Southern Cross University, under professional supervision. These services aim to improve the health and wellbeing of homeless population utilising SPACC St Johns Drop-in Centre. Delivery of GP services until transition to alternative general practices is achieved.

DURATION 1 July 2015 - 30 June 2016 Description

HealthyGC is a program for disadvantaged, homeless and vulnerable clients visiting “St John’s Drop-In-Centre”. Many of these clients do not seek primary health care services due to self-esteem/confidence/mental health issues. Originally submitted in 2013/14 under the Innovation Grants where equipment to accommodate the proposed services (such as flexible partitions, hand washing facilitates etc) was implemented. In 2014/15 GP, Podiatry and Social Work services were implemented on-site through contracted arrangements.



Podiatry services will continue to be delivered on site by students from Southern Cross University with appropriate clinical supervision. In February 2015 a Social Work “Student Hub” commenced with students from Southern Cross and Griffith Universities providing advocacy, assessment, case management, crisis intervention and group programs.

During 2014/15 GP services commenced under a contracted arrangement for 1.5hours per week on site, with administrative support provided by GCML. Evaluation of the GP and Allied Health Services provided has shown an increased need for Social Work services. Better value for money and more comprehensive service provision can be gained with the Social Workers linking clients to mainstream General Practice within Surfers Paradise and also providing support to clients to follow through on referral, radiology and pathology which Is not currently happening. As a result the on-site GP services will be phased out at the beginning of 2015/16 and the Social Work student supervisor will be increased from 0.3 to 0.8 FTE, with an 2 additional students placed in the Student Hub increasing their capacity to work more comprehensively with clients and assisting in linkages with GP and other mainstream services in the local area.

Type of activity

Provision of student lead Podiatry services and Social Worker services, including; case management, crisis intervention, advocacy, referral & assessment and Group intervention programs and delivery of GP services until transition to alternative general practices is achieved

Region Homeless (at risk of homelessness) clients accessing SPACC – St Johns Drop In Centre in Surfers Paradise

Sector Socio economic disadvantage, Homelessness

Service Provision Purchased Primary Allied health Podiatry services from Southern Cross University to provide Podiatry Students under professional supervision.

Purchased Primary Allied health Social Work supervisor from Surfers Paradise Anglican Crisis Care, for Southern Cross & Griffith Universities to provide social work students under professional supervision

Performance information Include headline indicator (% immunised, % reduction in preventable admissions) and applicable process indictors

• %increase in access to services for targeted groups • %of key stakeholders that value GCML engagement

Expected outcome • Increase in homeless and disadvantaged people accessing primary care services. • Improved health status for consumers attending SPACC.



• Improve consumer confidence and health awareness/literacy to seek appropriate services. • Improved placement opportunities for podiatry and social work students (identified area workforce shortage)

Milestones July – 30 June 2016 • Continuation of Social Work Student Hub and weekly Podiatry Clinics • Monthly reporting on Podiatry and Social Work outcomes (as above).

Delivery of GP services until transition to alternative general practices is achieved’. [SERVICE ACCESS – HEALTHY GC] STRATEGIC GOAL

Link to PHN Objectives ACTIVITY NAME Service Access – HealthyGC 1,2 IDENTIFIED NEED Community consultation, Taking the Pulse (TTP) 2012-2013 identified that lack of information was identified as a

barrier to accessing services Stakeholder consultation for HWP – 2012. The 2012 summit priorities – Access to information was a key theme – web based single point of access for information local information, current across community and health service providers, multiple access points (“wellness centres”) build on existing services eg libraries and GPs, direct people back to the one information source.

STRATEGY Increase access to services through Web based information DURATION Ongoing Description

A comprehensive web based health and wellbeing information portal has been identified by service providers and the community on the Gold Coast as the most effective way to provide readily accessible and up to date information. In response to the PCGC has continued to increase access to information services for the population through the following strategies:

• PCGC will continue to host, market and maintain a web portal featuring a LOCAL service directory and to increase awareness of services available and facilitate collaboration and integration of services.

• Grow service directory listings and encourage self-management of listings. Promote web-site and directory through collateral, publications, social media, practice visits and other program areas.

• Review of referral pathways and resources in key areas (building on existing guidelines and templates and resources)

• Pathways and referral templates and resources linked with directory listing to facilitate access and referral options.

• Work cooperatively with National Health Service Directory Type of activity Education/information, Integration and Coordination,



Region Whole of PHN Sector All GC population Service Provision PHN directly Performance information Include headline indicator (% immunised, % reduction in preventable admissions) and applicable process indictors

4. % increase in access to services for targeted groups. 8. % of key stakeholders that value PHN engagement

Expected outcome • Provision of comprehensive listing of primary health care service providers • Provision of Customized listings for Telephone & Online Services. • Increase access to service information for service providers and consumers.

Milestones August 2015 • Gold Coast Integrated Care program to commence using service directory in record point September 2015 • Establish process to promote regular use/update by HealthyGC members – • Additional directory development for new features completed October 2015 • Website restructure and redesign

Documents

OPERATIONAL AND FLEXIBLE FUNDING - HealthyGC · PDF file• Majority of allied health providers trained in RecordPoint • Strategy for Aged Care component developed . October –