Activity Work Plan :

Transcription

1 Activity Work Plan : Core Funding General Practice Support Funding After Hours Funding Brisbane South PHN Activity Work Plan (Core Funding, General Practice Support Funding, After Hours Funding) V1 16 April 2018 (D ) 1

2 Overview The key objectives of Primary Health Networks (PHN) are: Increasing the efficiency and effectiveness of medical services for patients, particularly those at risk of poor health outcomes; and Improving coordination of care to ensure patients receive the right care in the right place at the right time. This Activity Work Plan covers the period from 1 July 2018 to 30 June (a) Strategic Vision for PHN The Brisbane South PHN Strategic Plan 2017 Onwards details the PHN s vision of Better System, Better Health. The Brisbane South PHN vision is to achieve a well-coordinated primary health sector improving whole-of-life health and wellbeing across our region. Activity Work Plan (Core Funding, General Practice Support Funding, After Hours Funding) V1 16 April 2018 (D ) 2

3 Contents Core Flexible Funding Stream CF 2.1 Aged Care Navigation... 4 CF 5.1 Early Years Allied Health... 6 CF 5.2 Domestic and Family Violence... 9 CF 5.6 Advance Care Planning Core Operational Funding Stream: Health Systems Improvement General Practice Support Funding HSI 2.1 Older People Health and Wellbeing Strategy HSI 3.1 Digital Health Enablement HSI 5.1 Maternal Shared Care HSI 5.2 Multicultural Health HSI 5.3 Optimal Care HSI 5.4 Person Centred Collaborative Care Practices (PCCCP) HSI 5.5 Person Centred Collaborative Care (PCCC) HSI 6.1 Practice Nurse Support Program HSI 6.2 Workforce Development and Education HSI 7.1 HealthPathways HSI 7.2 Population Health Planning, Monitoring and Reporting HSI 7.3 Stakeholder Engagement GPS 1.1 General Practice Support After Hours Primary Health Care Funding AH 5.1 CALD Health System Navigation Project AH 5.2 Domestic and Family Violence AH 5.3 Homeless Health AH 7.1 After Hours Service Response AH 7.2 Emergency Department Avoidance Campaign Activity Work Plan (Core Funding, General Practice Support Funding, After Hours Funding) V1 16 April 2018 (D ) 3

4 1. (b) Planned PHN activities Core Flexible Funding Stream Proposed Activities Activity Title / Reference CF 2.1 Aged Care Navigation Existing, Modified, or New Activity New Program Key Priority Area Select one of the following: Aged Care Priority One: Targeted health conditions, p. 176 Possible option: Needs Assessment Priority Area - Engagement and involvement: Map the patient journey to gain a deeper understanding of barriers and issues. Considerations to identified vulnerable populations (including socioeconomically disadvantaged areas) Aim of Activity To assist vulnerable and at-risk older persons in accessing aged care services, following recent aged care reform that has seen a transition to self (consumer)-directed care. Objectives: 1. Investigate the issues, barriers and enablers to vulnerable consumers, family/carers accessing aged care assessment and screening services. 2. Develop and implement a solution to streamline access to aged care services that meet the identified needs of the different vulnerable groups. The changes associated with the aged care reform have been easier for some older people than for Description of Activity others depending on their physical wellbeing, health literacy, computer skills, support networks and other factors. Already vulnerable populations within the Brisbane South PHN region such as Aboriginal and Torres Strait Islander peoples, multicultural communities and people who are vulnerably housed are particularly at risk of not being able to successfully navigate the system and maximise their use of self-directed care initiatives. Expected outcomes: - Improved understanding of, and access to, aged-care functionality for vulnerable older adults within the Brisbane South region. Target population cohort Older adults in the Brisbane South PHN region, with a focus on Aboriginal and Torres Strait Islander peoples, multicultural communities, and people who are vulnerably housed. Consultation - HSI Component Consultation activity Status 4

5 Assessing need Reviewing service provision Deciding priorities Planned Planned Planned Collaboration - HSI Component Stakeholder Planning Co-design Procurement Implementation Monitoring Evaluation HSI Component Other Indigenous Specific Duration Coverage Commissioning method Decommissioning Funding from other sources Consumers - - Primary health care providers - - Hospital and Health Service - Planning, co-design, procurement, and monitoring and evaluation. No. Key milestones Start date Completion date Planning Q Q Implementation Q Q Commencement of service delivery Q Whole of Brisbane South PHN region (PHN302). Commissioned in full. Not applicable. Not applicable. 5

6 Proposed Activities Activity Title / Reference CF 5.1 Early Years Allied Health Existing, Modified, or New Activity Modified (NP 3.2 Imago, NP 3.3 Allied Health Intervention) Program Key Priority Area Select one of the following: Population Health Priority One: Targeted health conditions, p. 170 Possible option: - Address social determinants: participate in collaborative efforts to address social determinants that have an impact on health outcomes of developmentally vulnerable Needs Assessment Priority Area children. Priority Four. Targeted vulnerable populations, p. 184 Possible option: - Equitable access to services: Support primary care and related cross-sector partners to improve screening for children at risk of developmental delays. To integrate child health and wellbeing services in primary health care with services in the broader Aim of Activity health and education sectors to improve child health and wellbeing, and support for parents and families. Early Years Allied Health will address the above Needs Assessment priority areas through commissioning a provider(s) to improve equitable access to services (as noted above) and building capacity of the Early Years sector. Objectives: 1. Empowerment and capability-building of Early Years Centres and NGO family organisations to identify children with developmental vulnerabilities. 2. Screening children and providing early intervention (targeted allied health services) for those children identified as developmentally vulnerable. Description of Activity 3. Building capacity in the Early Years sector to promote healthy lifestyles for children and families to assist with prevention of common conditions (such as poor oral health, injury and childhood obesity). 4. Facilitating improved integration and coordination of health and related services for children and families. 5. Identifying opportunities and partnerships within youth and family services with a focus on child health, child development, child and adolescent mental health, paediatric, maternity services and primary care. 6

7 Target population cohort Consultation - HSI Component Expected outcomes: - Improved identification of children at risk of developmental delays. - Integration of services and reducing current fragmentation that adversely affects quality, cost and, health outcomes. - Improving access to services including availability, proximity, affordability, timeliness, appropriateness, and awareness. - Establishing a clear point of accountability for integrated service planning and delivery. Children and families/carers, Early Years centres, family non-government organisations, and primary health care providers in the Brisbane South PHN region. Consultation activity Status Assessing need Completed Reviewing service provision Completed Deciding priorities Planned Stakeholder Planning Co-design Procurement Implementation Monitoring Evaluation Collaboration - HSI Component HSI Component Other Indigenous Specific Duration Consumers - Primary health care providers - Hospital and Health Services - Child developmental service providers Early childhood education providers Other State and/or Federal Departments Local Government Non-government organisations Planning, co-design, procurement, monitoring and evaluation. No. Key Milestone Start date Completion date Planning Q Q

8 Coverage Commissioning method (if known) Decommissioning Funding from other sources Procurement Q Q Commencement of service delivery Q Q Whole of Brisbane South PHN (PHN302), with a focus on areas where a high proportion of children experience developmental vulnerability (in at least one domain). Commissioned in full. Not applicable. Not applicable. 8

9 Proposed Activities Activity Title / Reference CF 5.2 Domestic and Family Violence Existing, Modified, or New Activity New Program Key Priority Area Select one of the following: Population Health Priority One. Targeted health conditions, p. 177 Possible option: - Engage with cross-sector organisations to improve access to services as required E.g. linking Needs Assessment Priority Area to QPS for DFV support, or building partnerships to share data related to DFV Priority Four: Targeted vulnerable populations, p. 187 Possible option: - Support primary care services to identify and appropriately respond to people experiencing domestic and family violence To build connections between relevant services to better support people experiencing domestic and Aim of Activity family violence (DFV), through enabling continuity of care across the continuum of within and after hours care. This component of the DFV project will achieve this through workforce support and development in the region. Objective: 1. Strengthen relationships between primary care services and DFV specialist services to improve service integration and develop effective care pathways using a co-design process. This will be achieved through the development of referral forms, engagement tools, HealthPathways, whole of practice support, and education to promote antenatal screening and sensitive inquiry in primary care. This Activity is related to After Hours Activity AH 2.1. Expected outcomes: Description of Activity - Primary care services are better resourced and supported to effectively identify and engage with people experiencing DFV - Primary care practice staff have appropriate skills, knowledge and confidence in managing DFV - Primary care services have developed safe and trauma informed responses to disclosure of people experiencing DFV - People experiencing DFV receive prompt, seamless and safe access to specialist support for DFV 9

10 Target population cohort Consultation - HSI Component Providers of care to people experiencing domestic and family violence, particularly primary care staff, and specialist domestic and family violence services, in the Brisbane South PHN region. Please note, this activity is not funded through HSI. However, details regarding consultation are noted below. Consultation activity Status Assessing need Completed Reviewing service provision Completed Deciding priorities Completed Please note, this activity is not funded through HSI. However, details regarding collaboration are noted below. Collaboration - HSI Component Stakeholder Planning Co-design Procurement Implementation Monitoring Evaluation HSI Component Other Indigenous Specific Duration Coverage Consumers - - Primary health care providers - - Hospital and Health Services - - Specialist DFV services Research partners This activity will not utilise HSI funding. No. Key Milestone Start date Completion date Planning Ongoing Q Procurement Q Q Commencement of service delivery Q Q Whole of Brisbane South PHN region (PHN302), with a focus on the SA3s of Brisbane Inner (30501), Brisbane Inner East (30502), Forest Lake-Oxley (31001), Wynnum-Manly (30103), Mt Gravatt (30303), Beenleigh (31102), Browns Plains (31103), Loganlea-Carbrook (31105), Jimboomba (31104), and Springwood-Kingston (31106). 10

11 Commissioning method (if known) Decommissioning Commissioned in full. Not applicable. 11

12 Proposed Activities Activity Title / Reference CF 5.6 Advance Care Planning Existing, Modified, or New Activity Modified (NP 6.3 Advance Care Planning) Program Key Priority Area Select one of the following: Population Health Priority Two: End-of-life Care, p. 181 Possible option: Needs Assessment Priority Area - Provide education and support to primary care practitioners and staff to inform the local community on existing services, particularly for aged/seniors. This may include Advance Care Planning. Aim of Activity To improve the quality of end-of-life planning and end-of-life care for residents of residential aged care facilities in the Brisbane South PHN region. The Advance Care Planning activity expands on a program implemented by Brisbane South PHN in , which supports residential aged care facilities to embed an evidence-based Advance Care Planning program in routine clinical care, to support high quality end-of-life care. Objectives: 1. Further development, promotion and evaluation of Advance Care Planning adoption, and other end-of-life interventions, across registered residential aged care facilities. 2. Ongoing mentor support and resources (aligned with Metro South Hospital and Health Description of Activity Service End-of-life Framework) to support adoption of best practice methods. This will be achieved through education events and resources to support Advance Care Planning Champions and Palliative Approach Link Nurses in residential aged care facilities. Expected outcomes: - Improved Advance Care Planning adoption within residential aged care facilities, and improved quality of end-of-life care for residents and their families/carers - Contribution to the evidence base to support the cost effectiveness of implementing Advance Care Planning programs Target population cohort Primary health care providers and non-clinical staff within residential aged care facilities in the Brisbane South PHN region. Consultation - HSI Component Consultation activity Assessing need Reviewing service provision Deciding priorities Status Completed Ongoing Completed 12

13 Collaboration - HSI Component HSI Component Other Indigenous Specific Duration Coverage Commissioning method (if known) Decommissioning Stakeholder Consumers - - Primary health care providers - - Hospital and Health Services Residential aged care facilities Planning, co-design, procurement, and monitoring and evaluation. No. Key Milestone Start date Completion date Planning Q Q Procurement Q Q Commencing service delivery Q Q Whole of Brisbane South PHN region (PHN302). Commissioned in full. Not applicable. Planning Co-design Procurement Implementation Monitoring Evaluation 13

14 1. (c) Planned PHN activities Core Operational Funding Stream: Health Systems Improvement General Practice Support Funding Proposed Activities Activity Title / Reference HSI 2.1 Older People Health and Wellbeing Strategy HSI/GPS Priority Area Select one of the following: System Integration Existing, Modified, or New Activity New To facilitate a collaborative and joint approach to working with older people in the Brisbane South Aim of Activity region following recent aged care reform that has changed the way older persons health care services are delivered. The Older People Health and Wellbeing Strategy will address Needs Assessment Priority Two: End-oflife care. Objectives: 1. Identify barriers to access and other issues that are increased for vulnerable communities, such Description of Activity as Aboriginal and Torres Strait Islander peoples, multicultural communities and people who are vulnerably housed. 2. Investigate and identify local issues, barriers, emerging trends, and health priorities that impact on consumer health, use of health services, health professional satisfaction, and demands on the health system. 3. Jointly plan for population health initiatives and services to address identified need(s). - Engage with GPs and other primary health care providers to identify and design solutions to address relevant health issues identified by stakeholder groups. Supporting the primary health care sector - Collaborate with all relevant regional health services and providers to address and improve integrated care pathways and the delivery of coordinated, effective and efficient care. - Actively support broad primary health care improvement. 14

15 Collaboration Stakeholder Planning Co-design Procurement Implementation Monitoring Evaluation Consumers Primary health care providers Hospital and Health Services - Duration Key Milestone Start date Completion date Planning Q Q Procurement Q Q Commencement of service delivery Q Q Coverage Whole Brisbane South PHN region (PHN302). - Development of a joint strategy with Hospital and Health Service(s) to address findings from the activity - Implementation of the strategy would benefit the local aged care sector with a focus on Expected Outcome meeting the health and service needs of vulnerable older populations and re-ablement where appropriate. Subsequent anticipated outcomes include: o Improved consumer experience, carer experience and consumer quality of life o Improved access to appropriate in-home care services for older adults 15

16 Proposed Activities Activity Title / Reference HSI 3.1 Digital Health Enablement HSI/GPS Priority Area Select one of the following: Digital Health Existing, Modified, or New Activity Existing (NP 10.2 Digital Health) To facilitate the development of a clinical culture that embraces meaningful use of digital health Aim of Activity technologies. Digital Health Enablement will address Needs Assessment Priority Six: Service integration, co-ordination and navigation. Digital Health Enablement will provide support to general practices, allied health, pharmacy, and other healthcare providers in the region to improve the uptake of digital health technologies. Objectives: Description of Activity 1. Support the adoption and use of digital health technologies and initiatives that support clinical decision making and referral pathways, such as Secure Message Delivery, Queensland Health Integrated Referral Management Systems initiative, and Telehealth. 2. Support general practices to increase their use of interoperable structured data and consistent terminology in healthcare applications to enhance data quality and analysis that enables decision support, proactive planning and quality improvement - Enhance effective communication and collaboration between healthcare professionals Supporting the primary health care sector - Support efficient delivery of health care Stakeholder Collaboration Primary health care providers - - Hospital and Health Services - - Australian Digital Health Agency - - Professional peak bodies Software vendors Duration Key Milestone Start date Completion date Planning Completed - Planning Co-design Procurement Implementation Monitoring Evaluation 16

17 Coverage Expected Outcome Procurement Completed - Commencement of service delivery Q Ongoing Whole of Brisbane South PHN region (PHN302). - Increased uptake and usage of digital health technologies by the primary care workforce in the Brisbane South PHN region - Data quality improvements, and generation of actionable data within participating primary healthcare providers - Effective use of actionable data and knowledge for evidence-based decision making - Population health and patient-centric chronic disease management - Patient engagement - Improvement in patient outcomes 17

18 Proposed Activities Activity Title / Reference HSI/GPS Priority Area Existing, Modified, or New Activity Aim of Activity Description of Activity Supporting the primary health care sector HSI 5.1 Maternal Shared Care Select one of the following: Other (please specify) If Other, please provide details: Workforce development Existing (NP 2.2 Maternal Shared Care) To enable GPs, midwives, and obstetricians to provide high quality antenatal and postnatal care, through improved knowledge on evidence-based practices seeking to deliver women-centred care and improved patient management during the perinatal period. Maternal Shared Care will address Needs Assessment Priority Four: Targeted vulnerable populations. Objective: 1. Deliver educational events to GPs, midwives, and obstetricians with a focus on evidence-based practices seeking to deliver women-centred care and improved patient management during the perinatal period a. Presentations by local experts include combined first trimester screening, nuchal translucency scans, obesity in pregnancy, diabetes management in pregnancy and use of the Pregnancy Health Record. b. Facilitate participation in small, case-based discussions that include commentary and feedback from experts. Topics cover use of medication in pregnancy (particularly regarding antidepressants, vaccination and hyperemesis), domestic and family violence, and perinatal mental health. - Support health care providers to adopt best practice methods to improve the quality of care (specifically, antenatal and postnatal care). Collaboration Stakeholder Planning Co-design Procurement Implementation Monitoring Evaluation Clinical leads - - Hospital and Health Services - - Duration Key Milestone Start date Completion date Planning Completed Procurement Completed 18

19 Coverage Expected Outcome Commencement of service delivery Q Ongoing Whole Brisbane South PHN region (PHN302), with some additional coverage for other PHN regions due to patient flow i.e. some consumers and general practices are located outside of the Brisbane South PHN region. - Improved knowledge of GPs, midwives and obstetricians to provide high quality antenatal and postnatal care - Improved patient management 19

20 Proposed Activities Activity Title / Reference HSI 5.2 Multicultural Health HSI/GPS Priority Area Select one of the following: Other Practice Support Existing, Modified, or New Activity Existing (NP 1.1 Multicultural Health) To improve the health outcomes and experience of people from culturally and linguistically diverse (CALD) backgrounds by ensuring that: - primary health care is accessible and inclusive for people of CALD backgrounds Aim of Activity - people of CALD backgrounds receive culturally and clinically appropriate care - Brisbane South PHN continues to work with relevant parties to identify and address gaps in health for people of CALD backgrounds. Multicultural Health will address Needs Assessment Priority Four: Targeted vulnerable populations. Multicultural Health encompasses several smaller projects to improve health outcomes and experience for the large multicultural populations within the Brisbane South PHN region. This will be achieved through the following objectives noted below. Objectives: 1. Build capacity in primary care by: a. Providing general practice support, clinical lead support, clinical education, crosscultural training, clinical and administrative resources Description of Activity b. Providing navigation of services for providers, including centralised access point to assist services to navigate refugee health care c. Providing free access to interpreting services for Allied Health Professionals (AHPs) through the Interpreting for AHPs Program. 2. Build capacity and integration across the sector by: a. Upskilling other sectors about primary care e.g. settlement services, education b. Commissioning and/or working with partners to co-create sustainable models of care and health promotion opportunities for people from CALD backgrounds. Supporting the primary health care sector - Support health care providers to adopt best practice methods to improve the quality of care (specifically, culturally and clinically appropriate care). - Engage with GPs and other primary health care providers to identify and design solutions to relevant health issues identified by stakeholder groups. 20

21 - Collaborate with all relevant regional health services and providers to address and improve integrated care pathways and the delivery of coordinated, effective and efficient care. Stakeholder Collaboration Consumers - - Primary health care providers - - Hospital and Health Services - Clinical leads Refugee and multicultural service providers Education providers Duration Key Milestone Start date Completion date Planning Ongoing - Procurement Ongoing - Commencement of service delivery Ongoing - Whole of Brisbane South PHN region (PHN302), with some additional coverage for the Brisbane North Coverage PHN region (PHN301), in alignment with the Department of Immigration Settlement Areas which include the LGAs of Brisbane (31000) and Logan (34590). - Improved access to culturally appropriate and safe primary healthcare services for people from Expected Outcome CALD backgrounds - Improved primary healthcare provider capability to deliver culturally appropriate services to people from CALD backgrounds Planning Co-design Procurement Implementation Monitoring Evaluation 21

22 Proposed Activities Activity Title / Reference HSI 5.3 Optimal Care HSI/GPS Priority Area Select one of the following: General Practice Support Existing, Modified, or New Activity Existing (NP 4.2 Optimal Care) To support general practices to enhance the care provided to people with chronic disease through Aim of Activity quality improvement initiatives and facilitation of communication, collaboration and knowledge sharing between clinical specialists and general practice teams. Optimal Care will address Needs Assessment Priority One: Targeted health conditions. Objectives: 1. Improve general practice staff knowledge and use of health analytics software for chronic disease management to inform practice 2. Improve general practice staff use of chronic disease and prevention Medicare Benefits Schedule (MBS) items, through education and support 3. Increase general practice staff knowledge and use of clinical disease management decision support tools, such as clinical care pathways and referral guidelines, and better capture of Description of Activity relevant patient biomedical data 4. Increase general practice staff knowledge of health coaching and chronic disease selfmanagement, to support patients to undertake lifestyle behaviour change 5. Optimise patient care by connecting with additional patient support offered by disease-specific NGOs 6. Improve GP capability to manage consumers with complex chronic conditions through models of care that facilitate collaboration between specialists and general practice teams e.g. Beacon clinics, Project ECHO. Supporting the primary health care sector - As per objectives outlined above. Collaboration Stakeholder Planning Co-design Procurement Implementation Monitoring Evaluation Consumers Primary health care providers

23 Hospital and Health Services - - Research partners - - Non-government organisations Duration Key Milestone Start date Completion date Planning Completed - Procurement Q Q Commencement of service delivery Q Q Coverage Expected Outcome Whole of Brisbane South PHN region (PHN302). - Improved clinical outcomes for people living with chronic conditions - Improved general practice staff knowledge and capability in managing consumers with chronic conditions 23

24 Proposed Activities Activity Title / Reference HSI 5.4 Person Centred Collaborative Care Practices (PCCCP) HSI/GPS Priority Area Select one of the following: Other Practice Support Existing, Modified, or New Activity Existing (IN 1.2 Health Care Home Foundations) To support practices to implement, or enhance, a Patient Centred Medical Home-type model within Aim of Activity primary healthcare practices, utilising Bodenheimer s 10 Building Blocks of High Performing Primary Care framework. Based on Bodenheimer s 10 Building Blocks of High Performing Primary Care, and employing Quadruple Aim to contextualise outcomes, PCCCP will focus on the general practice as the leader and cornerstone of an individual s health care team, in response to and in readiness of the Commonwealth s policy direction for primary care. The PCCCP program will deliver support to general practices to facilitate transformation towards a health care home model of care. PHN staff will continue to be trained to facilitate the transformation journey of practices and support will be customised based on the profile, needs and priorities of each individual general practice. PCCCP s will select from a menu of service offerings which will include a range of tools, techniques, training programs, and tailored reports. Clinical support Business and system support - Clinical governance models (particularly in a - Business processes e.g. lean and six sigma devolved environment) - Strategic, business and operational planning - Accountable care - Business continuity Description of Activity - Chronic and complex conditions models - Business analytics - Consumer activation, self-management and - Data driven improvement behavioural models - General practice profiling - Integrated team care models - Information technology and data capture and - Patient Reported Outcome Measures cleansing (PROMs) and Patient Reported Experience Measures (PREMs) - Maximising revenue through appropriate MBS item numbers and billing - Retrospective, comparative and predictive measuring and monitoring clinical related metrics Workforce support - Intensive business, clinical leadership and change management coaching and mentoring Digital Health support - Paperless practice - Clinical audit tools 24

25 Supporting the primary health care sector for staff within practices (including practice support staff, general practitioners, allied health professionals) - Training, education, work shadowing and placement support to enable and facilitate all staff to practice at the peak of their scope - Clinical decision support tools - Business decision support tools - Digital Health literacy support tools - Support primary health care providers to adopt best practice methods to improve the quality and safety of care (particularly, chronic and/or complex condition management). - Assist practices in the understanding and meaningful use of digital health systems in order to streamline the flow of relevant patient information across the local health provider community. - Support the development of health information management systems to inform quality improvement in health care, specifically, the collection and use of clinical data within practices. Collaboration Stakeholder Planning Co-design Procurement Implementation Monitoring Evaluation Consumers - - Primary health care providers - Hospital and Health Services - Duration Key Milestone Start date Completion date Planning Q Ongoing Procurement - - Commencement of service delivery Q Ongoing SA3s of Beaudesert (31101), Browns Plains (31103), Beenleigh (31102), Springwood Kingston (31106), Coverage Forest Lake Oxley (31001), Loganlea Carbrook (31105), and Cleveland Stradbroke (30102). - Improved patient experience of care - Improved health outcomes and population health Expected Outcome - Improving cost efficiency and sustainability - Improved provider experience 25

26 Proposed Activities Activity Title / Reference HSI 5.5 Person Centred Collaborative Care (PCCC) HSI/GPS Priority Area Select one of the following: System Integration Existing, Modified, or New Activity New To implement the Person Centred Collaborative Care (PCCC) approach to deliver integrated care Aim of Activity initiatives that encompass population health, acute, non-acute, community, primary care, and social services. PCCC focuses on making the consumer and their needs the centre of the care experience and aims to develop and support integrated approaches to health care delivery (such as an integrated approach to tackling diabetes currently in development with Metro South HHS) within the region by working differently across services and systems to break down silos known to fragment care delivery. PCCC will: - Provide wrap-around care for consumers with complex needs; and - Support and enhance the health system to make it easy for consumers and providers to navigate and access the care they need. Description of Activity Objectives: 1. Enhance primary care prevention, early intervention, management and outcomes for people with, or at risk of developing, chronic disease 2. Explore alternative, value for money, workforce models to support improved clinical outcomes, care coordination, patient and clinician experience e.g. allied health assistants, peer facilitators 3. Facilitate increased coordination with other health and social services to meet the needs of consumers in targeted geographical locations 4. Utilise collaborative partnership approaches to design, implement and commission integrated person centred care models (e.g. non-dispensing pharmacists in general practice in the six targeted geographical regions and in partnership with PCCCP s). - Support primary health care providers to adopt best practice methods to improve the quality and safety of care (particularly, chronic and/or complex condition management). Supporting the primary health care sector - Collaborate with all relevant regional health services and providers to address and improve integrated care pathways and the delivery of coordinated, effective and efficient care. - Actively support broader primary health care improvement. 26

27 Collaboration Stakeholder Planning Co-design Procurement Implementation Monitoring Evaluation Consumers - - Primary health care providers - Hospital and Health Services - Duration Key Milestone Start date Completion date Planning Q Ongoing Procurement Q Ongoing Commencement of service delivery Q Ongoing Coverage Whole of Brisbane South PHN region (PHN302). - Greater capacity, capability and quality of primary care to influence and facilitate improvements in health outcomes Expected Outcome - Reductions in potentially-preventable hospitalisations - Increased equity of access and value in service delivery (based on the Patient Centred Medical Neighbourhood concept) 27

28 Proposed Activities Activity Title / Reference HSI 6.1 Practice Nurse Support Program HSI/GPS Priority Area Select one of the following: General Practice Support Existing, Modified, or New Activity Existing (NP 9.1 Practice Nurse Support) Aim of Activity To up-skill the practice nurse workforce, leading to improved patient wellbeing through prevention, early intervention and self-management of chronic conditions. The Practice Nurse Support Program will address a number of Needs Assessment Priorities, from a workforce perspective. The Practice Nurse Support Program provides support to practice nurse roles (new, returning, and transitioning) within general practice by offering education workshops, in practice support and mentoring. Objectives: 1. Provide education workshops to new, returning and transitioning practice nurses on a range of primary healthcare topics; such as accreditation, chronic disease management, immunisation Description of Activity and vaccine management, preventive health and assessments, and wound management. 2. Provide in-practice support and mentoring to participating practice nurses. The existing program will be enhanced during the period by: - Developing an on-line process to optimise delivery of the existing PNSP - Expanding the PNSP to support the advanced practice nursing role by developing additional topics such as nurse led clinics, quality improvement and professional leadership - Supporting and integrating with other Brisbane South PHN programs: Optimal Care, Patient Centred Collaborative Care and QI PIP. - Support primary health care providers to adopt best practice methods to improve the quality of Supporting the primary health care sector care (across a broad range of topics, including chronic and/or complex condition management). - Promote and improve the uptake of practice accreditation. - Assisting practices to retain practice nurses through the provision of support Collaboration Stakeholder Planning Co-design Procurement Implementation Monitoring Evaluation Primary health care providers Education providers

29 Duration Key Milestone Start date Completion date Planning Completed - Procurement - - Commencement of service delivery Q Q Coverage Whole of Brisbane South PHN region (PHN302). - Improvements in practice nurse expertise, knowledge and satisfaction in the identified area Expected Outcome - Improved access to on-line education material and mentoring support - Evidence of greater integration across identified Brisbane South PHN activities 29

30 Proposed Activities Activity Title / Reference HSI/GPS Priority Area Existing, Modified, or New Activity Aim of Activity Description of Activity Supporting the primary health care sector HSI 6.2 Workforce Development and Education Select one of the following: Other (please specify) If Other, please provide details: Health workforce Existing activity (NP 9.2 Workforce Development) To provide primary health care providers and support staff with opportunities to improve their knowledge, skills and confidence, maintain professional currency, and support new workforce models. Workforce Development and Education will address a number of Needs Assessment Priorities, from a workforce availability and suitability perspective. Topics of focus may include person-centred, and culturally appropriate service provision; identification, and appropriate service responses for people experiencing domestic and family violence; identification and management of chronic conditions, mental health concerns, and alcohol and other drug misuse (including care coordination). Additional topics may be considered based on identified local needs, and quality improvement activities (e.g. periodic evaluation, content enrichment). Objectives: 1. Provide workforce development and education activities relevant to the level of experience (e.g. new, established, or seeking advanced knowledge and skills) and career aspirations of primary health care professionals and support staff. 2. Ensure workforce development and education activities are in alignment with evidence-based guidelines, and in compliance with continuing professional development standards set by professional accreditation/registration bodies. 3. Offer workforce development and education opportunities through a variety of modalities to improve equitable access, and use local education providers and subject matter experts (where feasible) to leverage regional experience. - Support primary health care providers to adopt best practice methods to improve the quality of care (across a broad range of topics). - Actively support broader primary health care improvement. Collaboration Stakeholder Planning Co-design Procurement Implementation Monitoring Evaluation 30

31 Primary health care providers incl. support staff - Hospital and Health Services - - Education providers - - Peak bodies Duration Key Milestone Start date Completion date Planning Q Q Procurement Q Q Service delivery Q Q Coverage Whole of Brisbane South PHN region (PHN302). Expected Outcome Improved knowledge of topics discussed (during education sessions) among primary health care providers, and improved skills and confidence in delivering related services (positive change in practice). 31

32 Proposed Activities Activity Title / Reference HSI/GPS Priority Area Existing, Modified, or New Activity Aim of Activity Description of Activity HSI 7.1 HealthPathways Select one of the following: Other (please specify) If Other, please provide details: Access and navigation Existing (IN 1.1 Integrated Care Pathways) To support health professionals in planning patient care through the primary, secondary, and tertiary health care systems within the local region. SpotOnHealth HealthPathways will address Needs Assessment Priority Six: Service integration, coordination and navigation. SpotOnHealth HealthPathways is based on HealthPathways, an initiative from the Canterbury District Health Board (CDHB) in Christchurch New Zealand. The pathways are designed to be efficient, simple and quick to use at the point of care. They reflect best clinical practice and support clinical decisions at the point of care. Original Canterbury pathways are localised through an iterative and collaborative process involving acute and primary care clinicians. Once completed, they provide an overview of local health services and best practice clinical information and resources for primary healthcare providers, including information on how to access services when referring patients. In September 2017, Brisbane South PHN, in partnership with Metro South Hospital and Health Service (MSHHS), introduced SpotOnHealth HealthPathways. This partnership supports collaborative activity to prioritise localise health pathways in areas of greatest clinical need in the region, localise and introduce them to primary care clinicians. Objectives: 1. Engage GP Clinical Editors, and other relevant subject matter experts to review Canterbury pathways and work with clinicians in the primary and acute sectors to localise then publish pathways. 2. Support intensive promotion and demonstration of the use of HealthPathways among primary health care professionals through Area Account Managers and other relevant PHN staff engagement, media and communications tools, and promotion at all relevant workforce development events. 3. Engage with key service providers in the region, including peak bodies for chronic conditions, and ensure that HealthPathways reflects a comprehensive view of support services available to meet health needs. 4. Collaborate and partner to ensure HealthPathways is a part of a strategic approach to long term health service integration in the region. 32

33 Supporting the primary health care sector - Support primary health care providers to adopt best practice methods to improve the quality of care (across a broad range of topics). - Collaborate with all relevant regional health services and providers to address and improve integrated care pathways and the delivery of coordinated, effective and efficient care. - Actively support broader primary health care improvement. Collaboration Stakeholder Planning Co-design Procurement Implementation Monitoring Evaluation Primary health care providers - Hospital and Health Services - Non-government organisations - Duration Key Milestone Start date Completion date Planning Completed - Procurement - - Commencement of service delivery Q Q Coverage Whole Brisbane South PHN region (PHN302) - Decrease demand on acute services where care could be delivered by primary health care - Improve access to acute services for those who need it most right time, right care, right place - Improve patient experience through clear information on their care journey and options Expected Outcome - Yield high general practitioner and practice nurse adoption of clinical best practice - Improve health service provider experience through consistent and up to date information on referral options and processes. 33

34 Proposed Activities Activity Title / Reference HSI 7.2 Population Health Planning, Monitoring and Reporting HSI/GPS Priority Area Select one of the following: Population Health Planning Existing, Modified, or New Activity New To manage knowledge, information and data to measure, monitor and report on population health and Aim of Activity wellbeing, health needs, risks inequalities and use of services; and monitor and measure performance, impact and outcomes to assist improvements in patient experience, population health and community benefit. Objectives: 1. Undertake a regional health needs assessment, including needs assessment for targeted vulnerable population groups, in cooperation with partners and key stakeholders. Description of Activity 2. Interpret and present data and information to better inform regional decision-making in primary health care and primary health service provision. 3. Monitor, evaluate, report, and improve on primary health services managed and commissioned by Brisbane South PHN, and the quality and performance of regional primary care provision. Supporting the primary health care sector - Promote evidence-based planning Stakeholder Collaboration Hospital and Health Services - - Internal stakeholders - - Primary healthcare providers - - State and Federal Government Departments - - Non-government organisations - - Research partners - - Duration Key Milestone Start date Completion date Planning Completed - Procurement - - Commencement of service delivery Q Q Planning Co-design Procurement Implementation Monitoring Evaluation 34

35 Coverage Expected Outcome Whole of Brisbane South PHN region (PHN302). 1. Clear understanding of current and future primary health needs of the region, which informs the design and delivery of primary health care services. 2. Shared approach to data management, health planning and performance monitoring involving partners and key stakeholders. 3. Improvements made to primary health care initiatives and service delivery, based on feedback from the performance monitoring process. 35

36 Proposed Activities Activity Title / Reference HSI 7.3 Stakeholder Engagement HSI/GPS Priority Area Select one of the following: Other (please specify) If Other, please provide details: Stakeholder engagement Existing, Modified, or New Activity New Aim of Activity To communicate, connect and inform the community and the primary health sector using a range of networking tools and digital media. Objectives: 1. Use a range of media channels to communicate relevant information, ideas and key messages to specific groups and the broader community. 2. Connect communities, groups and individuals to local resources and services that support their Description of Activity health and wellbeing. 3. Facilitate interagency communication and dialogue with local communities to improve health literacy. 4. Work to understand and help others understand the policy, political and system-reform processes that can be used to support health and wellbeing and reduce health inequalities. Supporting the primary health care sector - Strengthen collaborative partnerships and networks Stakeholder Planning Co-design Procurement Implementation Monitoring Evaluation Collaboration Consumers Internal stakeholders - Primary health care providers - Hospital and Health Services - Non-government organisations - Peak bodies - External networks and committees - Duration Key Milestone Start date Completion date Planning Completed - 36

37 Coverage Expected Outcome Procurement - - Commencement of service delivery Q Q Whole of Brisbane South PHN region (PHN302). - Brisbane South PHN Stakeholder Engagement and Communications Strategy completed and implemented; multimedia, multi-platform communications strategy and tools implemented; and stakeholder and partner engagement and satisfaction is improved. - Evidence of regular and effective participation in Brisbane South PHN initiatives by Clinical and Community Advisory Councils; other formalised partnerships in place and routinely monitored; and impact of collective decision making is evidenced. 37

38 Proposed Activities Activity Title / Reference GPS 1.1 General Practice Support HSI/GPS Priority Area Select one of the following: General Practice Support Existing, Modified, or New Activity Existing (OP 1 Stakeholder Engagement through Account Management) The Brisbane South PHN has an important and integral role to play in enhancing capability and building capacity for General Practice to identify and support their patients needs to improve health outcomes Aim of Activity for our community. This will be supported through activities designed to enhance integration and connectivity between health providers, support improvements in quality and efficiency, minimise risk, increase service provider satisfaction and enhance patient safety, health outcomes and experience. The primary health team supports GPs and the wider community of primary health care professionals in the adoption of best practice processes, increased awareness of appropriate referral pathways for patients, use of local clinical care pathways, uptake of accreditation, improved chronic disease management, and adoption and use of electronic health and digital technologies. Effective engagement and support for practices and health providers is critical to achieving these aims. Brisbane South PHN has adopted an account management model that ensures our stakeholders are supported through regular and targeted contact, by providing a central point of contact between our Description of Activity organisation and the local health community. Account Management Model The Brisbane South PHN region is divided into Area Account Manager "territories", with each responsible for facilitating the engagement and support for general practices, pharmacies and allied health providers within their designated territory. Area Account Managers visit all general practices at least every two to three months, and pharmacies and allied health providers as relevant. Support activities include: 38

39 Supporting the primary health care sector - promote and support General Practice accreditation - support the collection, collation, analysis and use of de-identified clinical data to influence quality improvement activities and best practice processes - development and implementation of a range of quality improvement activities to enhance capability and build capacity - disseminating information to promote the uptake of Brisbane South PHN programs, or those provided in collaboration with Metro South Hospital and Health Service (MSHHS) and other key partners - linking in other Brisbane South PHN program staff who can provide specific assistance (e.g. Practice Nurse Support, Optimal Care and Digital Health programs) - informing GPs and other primary healthcare providers of changes to service provision (e.g. changes to referral criteria and pathways, new services available) - facilitating connection between general practices and other primary health providers to develop practitioner relationships and referral networks, improve communication and better coordinate information and knowledge sharing. - Strengthen collaborative partnerships and networks; and identify, understand and listen to stakeholders, and align communication and engagement strategies to needs. Collaboration Stakeholder Planning Co-design Procurement Implementation Monitoring Evaluation Primary health care providers - - Hospital and Health Services - - Peak bodies Duration Planning and service delivery ongoing throughout Coverage Whole of Brisbane South PHN region (PHN302). Expected Outcome - Proactive and strategic engagement with general practice, and other primary health care providers, to inform and influence change. 39