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February 2014
1
Peninsula Model Alliances – Summary of Plans
Attachment 2
FMP - Health Priorities and Alliances
Priority Health Issue Alliance
Aboriginal Health • Aboriginal Health Alliance
Ageing • Ageing Well Alliance
Chronic Disease
• Chronic Disease Management
Alliance
• Prevention and Better Health Alliance
Mental Health
• Alcohol and Other Drugs Alliance
• Mental Health Alliance
Vulnerable Children and Families
• Children’s Health Alliance
• Ehealth Alliance 2
Attachment 2
Summary of Achievements
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7 Alliances meeting regularly with agreed work plans
5 Alliances with established working groups that have agreed or are developing measurable outcomes (2 Alliances currently establishing working groups)
An effective executive group (PMEG) that provides strategic leadership in local area planning and provides the authorising environment for the collaborative work of the Peninsula Model
A ‘live’ Peninsula Model website with plans for enhanced functionality being developed
Over 20 agencies, 15 private primary care providers, 10 GPs, and 5 consumers represented on Alliances
Additional GPs, providers and consumers being engaged through focus groups
Agreement on a common service redevelopment methodology and common tools to undertake work
Attachment 2
Building Foundations
The Peninsula Model provides a strong partnership platform that can deliver:
Intersectoral approaches and models of service delivery
Improved outcomes for clients
Government’s policy reform (eg. mental health, drug and alcohol, Close the Gap)
Joined up public and private services
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Attachment 2
Shared Goals
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The Peninsula Model partners have joint ownership of the Shared Goals of the Peninsula Model
Shared Goals Outcomes
Consumer (C) Address the service gaps for
local consumers
Accessible, equitable services that meet local consumer health needs
Service Delivery (SD)
Provide consumer-centred,
coordinated and integrated
services
Improved consumer health journeys
Health Promotion (HP)
Impact the long term health of
the local community through
targeted and impactful health
promotion initiatives
Improved long term health of the community
Service System (SS)
Improve capacity to deliver
evidence based care
Resources and capabilities better aligned to meet local needs at a consistent high standard
Attachment 2
Children’s Health Alliance
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Key Priorities:
1. Streamlined pathways to early intervention services for children with developmental delay
2. Improved access to services and supports for vulnerable families
3. Advocacy that delivers more early intervention services targeted to those most in need
Attachment 2
Membership Peninsula Model Alliance: Children’s Health Alliance Membership – February 2014
Organisation Name Title
Chair - Peninsula Health Community Health Karen Anderson Program Manager Child & Family Services
Biala (ECIS) Marlene Fox Manager
Frankston City Council Mandy Gatliff Family & Youth Manager
Mornington Peninsula Shire Council Liz Palk Maternal & Child Health Coordinator
Mornington Peninsula Shire Council Karen McFarland Early Years Community Facilitator (Best Start)
Sprout Paediatric Therapy Services Monica Leo Director
Consumer Representative Lisa Guest Consumer
Peninsula Speech Pathology Services, PAHN Megan Ingram Principal Speech Pathologist
Frankston-Mornington Peninsula PCP
Peninsula Health Kathy McMahon Director of Paediatrics
South Coast Medical Centre, Blairgowrie Dr Damian Flanagan GP
Ballarto Medical Centre, Carrum Downs Dr Ehab Mostokly GP
Department Human Services Judith Luttrell Health & Education Assessment Coordinator
Anglicare Steve Watkinson Manager Families Services
Department Education and Early Childhood
Development Dennis Pratt Senior Regional Advisor Performance & Planning
Frankston-Mornington Peninsula Medicare Local Dr Helen Keleher Director Population Health Planning & Stakeholder
Relations
Allied Health Linda Biddle Mental Health Nurse
Frankston-Mornington Peninsula Medicare Local Ruth Azzopardi Director of Service Development
Frankston-Mornington Peninsula Medicare Local Suzanne Heppell Project Officer (Alliance Secretariat)
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Attachment 2
Key Outcomes Short Term (6 - 12mths)
Care pathways –development of two aged based care pathways (that includes public & private services)
Service navigation resources for providers and consumers distributed to all GPs, & promoted face to face with 20 GP practices
Trial of a new collaborative care model in 2 general practices
Streamlined approaches to 3½ yr health checks between GP & MCHN
A minimum of 15 GPs engaged in universal educational events
Medium Term (12mths – 2 yrs)
Reduced waiting lists for early intervention services
Increased participation of children and vulnerable families in primary health services
Increased GP referrals to ECIS, PH and private providers (using AH active partners) by 15%
Increased number of Expanded Healthy Kids Check by 15%
Long Term (2 – 5yrs )
More services available for children and vulnerable families
Increased number of children & vulnerable families accessing services
8
Attachment 2
Chronic Disease Management Alliance
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Key Priorities:
In relation to 1.Chronic Pain 2.Chronic Heart Failure and 3.Diabetes (Type 2) develop a catchment approach to:
Reducing the risk
Diagnosing early
Providing best care and support in the early stages
Providing best long term care and support
Providing best care and support during acute episodes
Attachment 2
Membership Peninsula Model Alliance: CDM Alliance Membership – February 2014
Organisation Name Title
Chair - Peninsula Health Iain Edwards Director Chronic Disease & Aged Services
Cranbourne Rd Medical Centre Susan Boucher General Practitioner
The Sports Injury Clinic Michelle Blake Physiotherapist
Terry White Pharmacy - Rosebud Gary Smethurst Pharmacist
Health Information Consultancy Christine Avery Diabetes Nurse Educator
PACE Health Management Ryan Poole Exercise Physiologist
Peninsula Health Vicki Davies Manager, Sub-acute Ambulatory Care Services
TBC Psychologist
Peninsula Health Linda Rabbidge Program Manager, Early Intervention In Chronic Disease
Mornington Peninsula Shire Council Peter Cracknell Coordinator, Intake & Assessment for Aged & Disability
Services
Frankston City Council Gretchen Strauss Coordinator, Community Care
Royal District Nursing Service TBC
St John of God Frankston Rehabilitation Hospital Sally Faulkner Director of Nursing
Frankston- Mornington Peninsula Medicare Local Ruth Azzopardi Director of Service Development
Frankston-Mornington Peninsula Primary Care
Partnership Christine Burrows Executive Officer
Frankston- Mornington Peninsula Medicare Local TBC Manager, Service Integration 10
Attachment 2
Key Outcomes Short Term (6 -12 mths)
Care pathways for Type 2 diabetes, chronic pain and chronic heart failure
Consistent dissemination of high quality consumer resources for Type 2 diabetes, chronic pain and chronic heart failure
New models and approaches to pain management and diabetes implemented
Improved consumer and service provider navigation of services
Improved coordination of care for people with chronic disease across the care continuum.
Medium Term (12mths – 2 yrs)
Improved HBa1C management across the catchment (60% of diabetic patients with Hba1C levels managed at ≤ 7)
Effective use of a telehealth solution by patients with chronic heart failure, that improves the management of symptoms, coordinates care and avoids unnecessary hospitalisations
Long Term (2 – 5yrs )
Reduced hospitalisations for people with pain, diabetes complications and chronic heart failure by 10%.
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Attachment 2
eHealth Alliance
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Key Priorities:
1. Facilitate the implementation of a Peninsula-wide eReferral capability
2. Improve the adoption of PCEHR across the FMP catchment
Attachment 2
Membership Peninsula Model Alliance: eHealth Alliance Membership – February 2014
Organisation Name Title
Chair - Peninsula Health Mark Gravell Head of IT Systems
Family Doctor, Frankston Joe Radcliffe General Practitioner
Mirella Timi and Associates Mirella Timi Psychologist
Baxter Pharmacy Bruce Hamilton Pharmacist
Peninsula Health Kim Wong Specialist
Peninsula Health Lyn Jamieson Clinical Systems Director
Peninsula Health Kim Dobson Manager, Mount Eliza Aged Care Assessment Service
Frankston City Council Leonie Reints Manager, Active Ageing and Disability Services
Mornington Peninsula Shire Council Jenny Van Riel Manager, Aged and Disability Services
MIND Australia Denis Hovic Area Manager, Outer South
Peninsula Support Services Terry Palioportas Chief Executive Officer
Headspace Frankston Rose-Mary Dowling Manager
Royal District Nursing Service Joy Jarratt Client Services Manager
Royal District Nursing Service Honni O’Day Development Co-ordinator – Solution Services
Brotherhood of St Laurence Lisa Rollinson Senior Manager, Community Aged Care
Frankston-Mornington Peninsula Medicare Local Ruth Azzopardi Director of Service Development
Frankston-Mornington Peninsula Primary Care
Partnership Christine Burrows Executive Officer
Frankston- Mornington Peninsula Medicare Local David Hutcheson eHealth Project Co-ordinator (Alliance Secretariat) 13
Attachment 2
Key Outcomes Short Term (6 -12 mths)
Procurement of an eReferral capability for use across the catchment
Effective implementation and use of the eReferral system by a defined group of early adopters
25% of GPs and pharmacists using PCEHR
Medium Term (12mths – 2 yrs)
FMP eReferral capability used across all core health service sectors
25% of allied health, RACFs and public services using PCEHR
50% of GPs and pharmacists using PCEHR
Long Term (2 – 5yrs )
Electronic interoperability between all provider groups
Secure transfer of health information
Improved patient journey through FMP health services
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Attachment 2
Prevention and Better Health Alliance
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Key Priorities:
1. Smoking prevention and cessation
2. Prevention of family violence, particularly violence against women and children, and improved access to services
3. Primary prevention of chronic disease through a place based approach
Attachment 2
Membership Peninsula Model Alliance: Prevention and Better Health Alliance Membership – February 2014
Organisation Name Title
Chair - Frankston Mornington Peninsula
Medicare Local Helen Keleher
Director, Population Health Planning and
Stakeholder Relations
Frankston Mornington Peninsula Primary Care
Partnership Vacant Integrated Health Promotion Coordinator
Peninsula Health Community Health Jon Adams Health Promotion Team Leader
Peninsula Health Community Health Christine Burrows Director, Child and Family Services
Frankston City Council Vacant
Department of Health, Southern Metro Region Monica Bensberg Senior Public Health Officer
Family Life Joe Cauchi Director of Partnerships and Special Projects
Women’s Health in the South East Sue Glasgow CEO
Frankston Mornington Peninsula
Medicare Local Emma Dunstan
Prevention and Better Health Coordinator (Alliance
Secretariat)
Monash University Vacant
Mornington Peninsula Shire Lisa Gray Team Leader, Health & Wellbeing
Peninsula Health Community Health Marg Martin General Manager, PH Community Health
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Attachment 2
Outcomes Short term (6mths-12mths):
Coordinated catchment plans for primary prevention that focus on disadvantaged groups for smoking cessation, family violence and chronic disease in working age adults.
Medium term (12-24mths):
Organisations working in partnerships across sectors, implementing evidence informed approaches to their primary prevention
Long term (2-5yrs):
New learnings and promising practices documented
Resources and activities integrated across organisations, sectors and settings
Reduced social and health inequalities
Improved quality of life for priority groups
17
Attachment 2
Aboriginal Health Alliance
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Key Priorities:
1. Establish a Koolin Balit Aboriginal Health Council to address health-related issues for Aboriginal people in FMP
2. Continue to strengthen Aboriginal culture
3. Deliver an Aboriginal community responsive prevention package locally in the catchment
4. Develop a coordinated Aboriginal Health service system
5. Empower sustainable Aboriginal community health.
Attachment 2
Membership Peninsula Model Alliance: Aboriginal Health Alliance Membership – February 2014
Organisation Name Title
Chair - Peninsula Health Shane Wright Cultural Ambassador
Department of Health, SMR Peter Sproules Area Manager, FMP Manager, Aboriginal Health
Peninsula Health Bel Berry Director, Complex Services
Mornington Peninsula Shire Jenny Macaffer Social Planning and Community Development
Willum Warrain Gathering Place Glenys Watts Secretary
Frankston Gathering Place Dianne Aiello Chair
Hastings Central Medical Muhammad Khalid Practice Manager
Mornington Peninsula Shire Beryl Wilson Community Development Officer
Headspace Rosemary Dowling Manager
DDAC- Bunurong Health Service TBC
Frankston LIN (Local Indigenous Network) Barry Firebrace
Bunurong Elder Aunty Caroline
Briggs Elder
Cranbourne Medical Centre Bradley Gray GP
Frankston Mornington Peninsula
Medicare Local Ruth Azzopardi Director, Service Development
Frankston Mornington Peninsula
Medicare Local Irene Fisher Aboriginal Health Manager
Department of Justice Tim Kanoa
Department Education and Early Childhood
Development Eric Clarke Koorie Education Coordinator
Brotherhood St Laurence Grant Lee 19
Attachment 2
Ageing Well Alliance
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Key Priorities:
1. Improve coordination and access to services for people living with dementia and their carers
2. Increase the number of people with Advance Care Plans (ACP) and the number of ACPs being respected
3. Identify vulnerable older people in the community who are not well connected and provide opportunities for these people to connect with each other and the general community
Attachment 2
Membership Peninsula Model Alliance: Ageing Well Alliance Membership – February 2014
Organisation Name Title
Chair - Brotherhood of St Laurence Lisa Rollinson Senior Manager, Community Aged Care
Peninsula Health Kim Dobson ACAS Manager
Pharmactive Rob Sztar Pharmacist, Vice President of PAHN
Frankston City Council Leonie Reints Manager, Active Ageing and Disability Services
Mornington Peninsula Shire Jenny Van Riel Manager, Aged and Disability Services
Peninsula Advisory Committee for Elders Margaret Godley Member
Peninsula Health Allan Carlow Program Manager for Aged Persons Mental Health
Peninsula Health Vicki Davies Manager Sub-Acute Ambulatory Care Services
Peninsula Family GP Dr Jenny Downes-
Brydon GP
Family Doctor Dr Joe Radcliffe GP
Royal District Nursing Service Glenda Valentine Client Services Manager
Peninsula Home Hospice Rachel Bovenizer CEO
Peninsula Health Iain Edwards Director, Chronic Disease & Aged Services
Frankston-Mornington Peninsula Medicare
Local Nick Jones Aged Care Project Officer (Alliance Secretariat) 21
Attachment 2
Key Outcomes
Short Term (6 -12 mths)
Service pathways for dementia and ACP
20% of GPs and practice nurses attend dementia and ACP training
Consistent ACP resources for providers and consumers
30% of new residents from 10 supported RACFs using the new ACP tool
90% of deceased people have their ACP respected and followed, preceding death at Peninsula Health
Social connectedness strategy
Medium Term (12 mths - 2 yrs)
30% of people aged 65+ have ACPs
Service providers understand and use dementia service pathway
Increased utilisation of dementia respite services
Long Term (2 – 5yrs )
90% of deceased people have ACP respected and followed preceding death
22
Attachment 2
Mental Health Alliance
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Key Priorities:
1. Development and implementation of a shared Peer Workforce Framework across the catchment
2. Improved access to services for rooming house residents, and development of sustainable long term housing options for people with mental illness
3. Streamlined pathways of care for people with mild to moderate depression
Attachment 2
Membership Peninsula Model Alliance: Mental Health Alliance Membership – February 2014
Organisation Name Title
Chair - Peninsula Support Services Terry Palioportas CEO
Peninsula Support Services Cindy Keys Operations Manager
Frankston City Council Liz Daley Manager Community Development
Volunteer d Coordinator, Seawinds Community
Hub Simon Dwyer Consumer Representative
Headspace Rose-Mary Dowling Manager
RDNS Alison Webb South & Eastern Team Coordinator, RDNS Homeless
Persons Program
IMPACT David Glazebrook CEO
Mental Illness Fellowship Sean Hegarty Regional Manager
MIND Australia Denis Hovic Regional Manager
Peninsula Health Bronwyn Lawman Director, Operations
Peninsula Health/PenDAP Sean Jespersen Director, Clinical Services
Peninsula Carer Council Aline Burgess Carer Representative
Mornington Peninsula Shire Council Peter Sibly Social Planner (Housing Justice and Advocacy)
Salvation Army Robert Martin Director of South East Services Network
Cranbourne Rd Medical Centre Meagan Lindorff Mental Health Nurse
Frankston-Mornington Peninsula Medicare Local Ruth Azzopardi Director Primary Care Services & Development
Frankston-Mornington Peninsula Medicare Local Sharon Collins Project Officer (Alliance Secretariat)
Frankston-Mornington Peninsula Medicare Local Sarah Brown Executive Director Primary Care Programs 24
Attachment 2
Key Outcomes Short Term (6mths)
Peer workforce framework
Service pathways for people with depression
Resources for providers and residents of rooming houses
Medium Term (18mths – 2 yrs)
Implementation and evaluation of Peer workforce framework
50% of rooming house residents with mental illness, linked to services
Long Term (2 – 5yrs )
Sustainable housing for people with mental illness
Strengthened partnerships, enhanced referral pathways and new models of care implemented
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Attachment 2
