Sue meteyard

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  • Report outcomes not unexpected

    61 Medicare Locals across Australia from 2011/12

    GCML commenced in July 2011

    Supporting less dependency on hospital services

    Change of name to Primary Health Networks
  • The resident population of the GCHHS/GCML Region is estimated to be 539,890 persons as at 30 June 2012. In the five years to 2012, the region experienced population growth of 12.5 per cent compared to 11.1 per cent and 9.0 per cent respectively for Queensland and Australia.
  • There is already much evidence of a willingness for the acute and primary care sectors to work together productively on the Gold Coast.

    Despite partnership efforts, there are still system frustrations between acute and primary sectors


  • GCHHS and GCML have a formal partnership which outlines specific objectives and targets in the form of an Annual Partnership Agreement which includes joint participation in planning and progressing plans: agreed objectives and targets; and joint funding of GPLO positions
    Primary Health Care Protocol was developed in accordance with Hospital & Health Boards Act 2011
    GC Lead Clinician Group
    GPGC
    Gold Coast Primary Care Council (PCPC)
    First came together in 2006 as a voluntary collaboration between organisations from government and non-government sectors in order to share information and improve coordination
    Established significant networks, collaborations and intellectual capital over the past five years
    Ensures integrated planning, delivery and evaluation that will meet the needs of the Gold Coast community and improve health and health related outcomes.
    Strives to make the most effective and efficient use of existing services through needs analysis, planning, service coordination and integrated service delivery.
    Acts as a fund holding body to administer grants from funding provided by Queensland Health to support the Queensland Chronic Disease Framework 2008 – 2015. The PCPC oversee a range of projects supported by the funds that have achieved better integrated services to meet community need.
    Became a member organisation of the Gold Coast Medicare Local (2012) the PCPC is supported by the Gold Coast Medicare Local when it was established in 2009 along with the Gold Coast City Council and Gold Coast Hospital and Health Service. The GCML continues to provide secretariat and partnering support and advice the PCPC.
  • Agreement to focus on COPD made at Leadership meetings
    Incidence of COPD higher than Qld average on Gold Coast
    GCHHS had clinicians keen to work in COPD space
  • GCML engaged 5 practices across the Gold Coast to become involved in a Quality Activity reviewing systems and processes
    How do practices identify and manage patients with COPD
    Development of KPIs
    Great results over a 9 month period
    Project team including
  • Navigation referral information: home oxygen, disability parking, Centrelink parking, Advanced Care Planning
  • Combined opportunities: COPD workshop & Afterhours training workshops
  • Level of readiness: Comprehensive needs assessment; need to add value consistently
    Trust & relationships: combined education sessions and networking forums, celebrate success, need face to face communication as well as electronic
    Building capacity: combined project work helps with transfer of knowledge and skills; need to prepare for the provision of 24/7 care in the community
    Change Management: provide required level of support dependent on outcomes of needs assessment; support needs to be tailored which also helps with resource allocation
    Sustainability: Need to ensure knowledge learnt is held within organisations; processes need to be documented
  • Sue meteyard

    1. 1. Linking Medicare Locals & Hospitals: How these services are working together to maintain the health and wellbeing of Gold Coast residents 24 July 2014 Medicare Locals gratefully acknowledge the financial and other support from the Australian Government Department of Health.
    2. 2. Today… Setting the Scene • The role of Medicare Locals • Partnering • Leadership Current Projects • Integrated Primary Health Care COPD project • Care coordination • Afterhours COPD project • Transitional Lungs in Action Lessons learnt
    3. 3. Role of Medicare Locals “Improve coordination and integration of primary health care in local communities, address service gaps, and make it easier for patients to navigate their local health care system” Horvath Report March 2014
    4. 4. A Day on the Gold Coast 576 people are admitted to hospital - 218 are preventable 93 women screened for breast cancer 41 people see a diabetic educator or a dietician The population increases by 30 people 4 to 8 12-25 year olds seek mental health services 7098 people see a GP 108 people see a psychologist Primary Care
    5. 5. Acute Care Presentations to Robina and GCUH emergency departments • 2012/13 - 125,730 • 2013/14 - 142,482 = 12 % increase
    6. 6. Partnering Shared Information & Technology Projects GP Liaison Positions Shared Education & Training Agreements & Committees Joint Innovative Project & Programs Combined HHS / Community funded positions
    7. 7. Leadership Joint participation in population health needs identification and service planning GCML / GCHHS Executive Steering Committee Engages other leading primary care organisations on the Gold Coast Primary Health Care Protocol Leads development and implementation of evidence based innovative models of care Gold Coast Lead Clinician Group Plays a lead role in improving and integrating health care through quality general practice General Practice Gold Coast Voluntary collaboration between government and non government sectors to share information and improve coordination Primary Care Partnership Council
    8. 8. Current projects
    9. 9. Aim: To develop an agreed service model for best practice COPD management From prevention through to end stage management Develop pathways to support communication & exacerbations Increased MDT communication & Improved Care Coordination Increased COPD screening Health literacy and other social determinants eHealth Reducing unplanned hospital presentations and /or admissions Improved experience for persons with COPD Integrated Primary Health Care COPD Project
    10. 10. The approach Practice Support • Prevention • Health literacy • eHealth • MDT communications • Pathways Allied Health • eHealth • MDT communication • Pathways – service directory Care Coordination • Care Coordination • Health literacy • MDT communication • eHealth • Improved patient experience GCHHS • Complex management • Reducing unplanned hospital presentations and/or admissions • eHealth • MDT Communication Education and Training
    11. 11. Practice support • October 2013 – June 2014 • 5 practices engaged • Variations in practice size and staffing • Developed a minimum data set looking at organisational and process data • Installation/training for PenCAT (data extraction tool) • Monthly CQI visits
    12. 12. Practice support achievements Baseline Current % Change (n=40) (n=202) Spirometry recorded 19% 39% ↑ 20% Current smokers 21% 28% ↑ 7% Smoking status NOT recorded 17% 6% ↓ 11% Fluvax vaccination recorded (within last 12 months) 28% 54% ↑ 26% Pneumococcal vaccination recorded (within last 5 years) 14% 22% ↑ 8% GPMP 28% 49% ↑ 21% TCA 31% 48% ↑ 15%
    13. 13. Allied health • November 2013 – June 2014 • 16 practices engaged • Solo, part-time practitioners through to large multidisciplinary practices across multiple sites • Private and non-government • Physiotherapy, Exercise Physiology, Occupational Therapy, Dietetics, Psychology, Pharmacy, Social Work and Speech Pathology • Developed a minimum data set looking at organisational and process data • Installation of Medical Objects
    14. 14. •↑ Use of Medical Objects for communication with GPs including acceptance, completion of initial and final reports in a timely manner •↑ Patients continuing treatment •↑ Amount of paperwork received at time of referral •↑ Two-way communication with GP’s via MO •↑ Understanding of what is happening with different disciplines •Finalised format of the COPD service directory •Knowledge about business practices (things aren’t always what they seem) •Confirmation that existing internal processes and systems are being followed and are effective Allied health achievements
    15. 15. • Based on Metro North Brisbane Team Care Coordination Program for Medicare Locals primarily providing a navigation function • Development of tools and processes to support communication • 21 referrals received from Jan 2014 to date from: • 5 engaged COPD practices (13) • GCHHS Chronic Disease Wellness Program (8) • Patients can be seen at home or in the practice setting • Case conference with GP and other service providers when needs are out of scope • Access to brokerage funds if required • Reviewing the patient experience to feedback into pathway development Care coordination
    16. 16. General Practice ↑ Access to eHealth ↑ PCeHR registrations ↑ Utilisation of MO following development of templates COPD Care plan, Case conference and COPD Action Plan, HMR ↑ Use of GPMP ↑ Case Conference attendance (4) GCHHS ↑ Referrals expected from GCHHS to support the Chronic Disease Wellness Strategy Care Coordination achievements
    17. 17. Afterhours COPD Program GCML in collaboration with GCHSS Chronic Disease Wellness Program Will provision of after hours nursing, physiotherapy, personal care and equipment result in reduced admissions for clients with ≥2 admissions for COPD in the previous year? Wellness Support Strategy COPD proactive care & monitoring- however no after hours response in event of after hours exacerbations Hospital presentation relating to after hours exacerbation-anxiety, lack of timely nursing review/chest physiotherapy, oxygen, equipment Extended hospital stay while awaiting oxygen, support at home, no supported transport home and resettling Partnership with GCML, participation in tendering process Service Agreement with Blue Care Procedure developed with endorsement of acute and specialist team Up skilling of Blue Care staff in COPD management Emergency Department based staff and Discharge Planners case find eligible clients Timely access to comprehensive community COPD assessments; feedback loop between acute sector and NGO Evaluation After Hours COPD Project Commenced January 2014 Opportunities from NGO re monitoring of clients who have stayed well with WSS
    18. 18. Afterhours COPD Program achievements Current activity • 17 referrals received for 7 COPD patients • All referrals were for physiotherapy • Unit cost per visit = $1100 • No adverse outcomes Planned modifications to the program • Increase support during peak times • Extend service to less complex respiratory patients • Ongoing education and communication of successes to build trust from acute sector for NGO involvement in patient care
    19. 19. Transitional Lungs in Action • GCML funding provided to GCHHS in the form of an “Innovation Grant”, January 2014 • Investigates the benefits and feasibility of introducing an additional program to patients at risk of discontinuing their treatment and self-management of COPD • Program builds on knowledge and skills learnt in Pulmonary Rehabilitation through structured and non- medically supervised exercise classes with the view to building the patients’ confidence to transition into a community based program
    20. 20. Education & Training Group • Spirometry • GCML & GCHHS combined opportunities • Motivational Interviewing • Regular networking forums Individualised at practice/NGO level • eHealth • MBS item numbers • CQI processes
    21. 21. Lessons learnt
    22. 22. Leading Change “Leading change requires not only a great idea but also the ability to mobilise individuals and organisations to embrace change” Accepting The Challenge Assessing Organisational Readiness Maximising Support Leading Transformation 2008 Advisory Board Company
    23. 23. • Assessment of organisational level of readiness • Building trust and relationships • Capacity building within the community • Change management • Sustainability Lessons learnt
    24. 24. Acknowledgements GCML • Andrea Sanders – Integrated Care Program Manager • Chris Ash – Care Coordinator (COPD) • Emma Briskey – Allied Health Project Officer • Fiona Hill – Primary Health Care Support Officer • Kathleen Kojima - Primary Health Care Support Officer • Bev Korn – Primary Health Care Support Program Manager • Sandra McElroy – Administration Support • Shane Patterson – Project Officer • Maureen Penwright - Primary Health Care Support Officer GCHHS • Judith Murrells – CNC Respiratory Services • Rose Costa – Acting Coordinator, Chronic Disease Wellness Program

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