Primary Health Networks Core Funding Primary Health Networks After Hours Funding

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1 Primary Health Networks Core Funding Primary Health Networks After Hours Funding Activity Work Plan Core Funding Annual Plan After Hours Primary Care Funding Annual Plan Northern Queensland Primary Health Network When submitting this Activity Work Plan to the Department of Health, the PHN must ensure that all internal clearances have been obtained and has been endorsed by the CEO. The Activity Work Plan must be lodged via to on or before 6 May

2 Introduction 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. Each PHN must make informed choices about how best to use its resources to achieve these objectives. Together with the PHN Needs Assessment and the PHN Performance Framework, PHNs will outline activities and describe measurable performance indicators to provide the Australian Government and the Australian public with visibility as to the activities of each PHN. This document, the Activity Work Plan template, captures those activities. This Activity Work Plan covers the period from 1 July 2016 to 30 June To assist with PHN planning, each activity nominated in this work plan can be proposed for a period of 12 months or 24 months. Regardless of the proposed duration for each activity, the Department of Health will still require the submission of a new or updated Activity Work Plan for The Activity Work Plan template has the following parts: 1. The Core Funding Annual Plan which will provide: a) The strategic vision of each PHN. b) A description of planned activities funded by the flexible funding stream under the Schedule Primary Health Networks Core Funding. c) A description of planned general practice support activities funded by the operational funding stream under the Schedule Primary Health Networks Core Funding. 2. The After Hours Primary Care Funding Annual Plan which will provide: a) The strategic vision of each PHN for achieving the After Hours key objectives. b) A description of planned activities funded under the Schedule Primary Health Networks After Hours Primary Care Funding. Annual Plan Annual plans for must: Activity Planning provide a coherent guide for PHNs to demonstrate to their communities, general practices, health service organisations, state and territory health services and the Commonwealth Government, what the PHN is going to achieve (through performance indicator targets) and how the PHN plans to achieve these targets; be developed in consultation with local communities, Clinical Councils, Community Advisory Committees, state/territory governments and Local Hospital Networks as appropriate; and articulate a set of activities that each PHN will undertake, using the PHN Needs Assessment as evidence, as well as identifying clear and measurable performance indicators and targets to demonstrate improvements. 2

3 The PHN Needs Assessment will identify local priorities which in turn will inform and guide the activities nominated for action in the Annual Plan. PHNs need to ensure the activities identified in the annual plan also correspond with the PHN Objectives; the actions identified in Section 1.2 of the PHN Programme Guidelines (p. 7); the PHN key priorities; and/or the national headline performance indicators. PHNs are encouraged to consider opportunities for new models of care within the primary care system, such as the patient-centred care models and acute care collaborations. Consideration should be given to how the PHN plans to work together and potentially combine resources, with other private and public organisations to implement innovative service delivery and models of care. Development of care pathways will be paramount to streamlining patient care and improving the quality of care and health outcomes. Primary Health Networks After Hours Funding From , PHNs will have greater flexibility to commission programme specific services, having completed needs assessments for their regions and associated population health planning. PHNs are funded to address gaps in after hours service provision and improve service integration within their PHN region. Item B.3 of the After Hours Funding Schedule may assist in the preparation of the After Hours components of your Activity Work Plan (pages of this document). Measuring Improvements to the Health System National headline performance indicators, as outlined in the PHN Performance Framework, represent the Australian Government s national health priorities. PHNs will identify local performance indicators to demonstrate improvements resulting from the activities they undertake. These will be reported through the six and twelve month reports and published as outlined in the PHN Performance Framework. Activity Work Plan Reporting Period and Public Accessibility The Activity Work Plan will cover the period 1 July 2016 to 30 June A review of the Activity Work Plan will be undertaken in 2017 and resubmitted as required under Item F.22 of the PHN Core Funding Agreement between the Commonwealth and all Primary Health Networks. Once approved, the Annual Plan component must be made available by the PHN on their website as soon as practicable. The Annual Plan component will also be made available on the Department of Health s website (under the PHN webpage). Sensitive content identified by the PHN will be excluded, subject to the agreement of the Department. It is important to note that while planning may continue following submission of the Activity Work Plan, PHNs can plan but must not execute contracts for any part of the funding related to this Activity Work Plan until it is approved by the Department. Further information The following may assist in the preparation of your Activity Work Plan: Clause 3, Financial Provisions of the Standard Funding Agreement; Item B.3 of Schedule: Primary Health Networks After Hours Funding; Item B.4 of Schedule: Primary Health Networks Core Funding; PHN Needs Assessment Guide; PHN Performance Framework; and Primary Health Networks Grant Programme Guidelines. Please contact your Grants Officer if you are having any difficulties completing this document. 3

4 1. (a) Strategic Vision Northern Queensland Primary Health Network s strategic vision of Making Health Better will be achieved by understanding need, strengthening partnerships and creating healthier communities. Our vision will be supported by aligning our strategies across six strategic objectives. Our activity work plan will be implemented by building a (1) coordinated, integrated and easy to navigate health system for both consumers, communities and health providers. A health system that is cohesive, structured and inherently connected, with patients getting the right service, at the right place, at the right time. Our vision is built upon (2) health intelligence and planning. We will ensure our consumers, communities and providers are well informed of their population health priorities and are empowered to take initiative to implement effective and efficient action locally that will produce a positive outcome. We will invest in (3) workforce capacity and capability. We will aim for a flexible and adaptable well-trained workforce (including non-clinicians), with the capacity and capability to deliver best care to patients while continuing to build skills through effective training and team work. (4) Strengthening partnerships and networking including leadership and advocacy will be key to our success. We will build strong partnerships and networking in primary care built on collaborative models, which strengthen relationships between health professionals, across the health sector and with consumers. Of key importance will be our high levels of (5) transparency, performance, quality and safety. We will aim for a strong framework of quality, safety and accountability in primary health care, based on improved information and quality assurance systems to support measurement, feedback and quality improvement for providers, and greater transparency for consumers and funders. This includes clinical and organisational governance, and risk management. We will invest in a strong (6) prevention and health promotion system. It will be standard practice to tackle the social determinants of health and wellbeing with emphasis on health promotion, prevention, screening, and early intervention. This will be implemented by high functioning collective impact partnerships, supporting local action on identified health promotion and prevention priorities, including local government and other relevant stakeholders. 4

5 1. (b) Planned activities funded by the flexible funding stream under the Schedule Primary Health Networks Core Funding 5

6 1. Aboriginal and Torres Strait Islander Health The objectives of NQPHN s involvement in Aboriginal and Torres Strait Islander health is making health better through a system that is free of racism and inequality, and for all Aboriginal and/or Torres Strait Islander people to have access to health services that are effective, high quality, appropriate and affordable. NQPHN acknowledges the importance of social determinants of health as a platform to improving health outcomes. NQPHN aims to commission a range of Aboriginal and Torres Strait Islander health initiatives to Indigenous people across North Queensland. In and onwards, we will: implement innovative and locally-tailored Aboriginal and Torres Strait Islander health initiatives, based on community need work to address gaps in Aboriginal and Torres Strait Islander health service provision, particularly in rural and remote communities within NQPHN. Proposed Activities Priority Area Activity Title / Reference Description of Activity Collaboration Aboriginal and Torres Strait Islander Health, Workforce, Chronic Disease, Rural and Remote Healthcare Access 1.1 Indigenous Health Workforce (New) The Aboriginal and Torres Strait Islander population is among the most vulnerable within NQPHN, and substantial investment is required to improve life expectancy and lifetime health. NQPHN recognises that the Aboriginal and Torres Strait Islander health workforce plays an important role in improving these health outcomes. NQPHN s Aboriginal and Torres Strait Islander health workforce program will implement a range of projects to develop and support Aboriginal and Torres Strait Islander health workers and workforce. This will ultimately lead to better health outcomes for Aboriginal and Torres Strait Islander communities. NQPHN employs a role to support and encourage the increase of Aboriginal and Torres Strait Islander Health workers (training and professional development), encourages and assists Aboriginal and Torres Strait Islander students in health related-disciplines, and supports Aboriginal and Torres Strait Islander health professionals with continuing professional development and postgraduate studies. The outcome of this activity will support and grow the Aboriginal Community Controlled Health Organisation (ACCHO) and mainstream health sector workforce, and is capable of meeting the needs of Aboriginal and Torres Strait Islander people in NQPHN s region. NQPHN will work side-by side with the mainstream health sector, Aboriginal Community Controlled Health Services, and Hospital and Health Services (HHSs). 6

7 Duration Anticipated activity in May 2016 and completion date in May Coverage Commissioning approach The geographic coverage of the activity will be the entire NQPHN footprint. NQPHN will employ an Aboriginal and Torres Strait Islander Health Workforce Development Coordinator to coordinate and facilitate Aboriginal and Torres Strait Islander health workforce development and clinical education initiatives across NQPHN s region. For services commissioned under this activity, NQPHN will directly approach the most capable provider, ensuring that all due diligence and required governance arrangements and a suitable and efficient model are in place. At the time of this approach, if there is an indication that there may be other suitable providers, then NQPHN will firstly advertise to invite Expressions Of Interest. Monitoring of performance will be conducted based on factors such as the level of risk, value, and impact of the contract. This will be assessed, and will determine the level and frequency of reporting. Specific contract managers within the organisation will be identified and meet regularly with the provider to understand any barriers, opportunities or improvements. NQPHN will conduct ongoing monitoring and evaluation of the contract. Sources such as patient feedback, complaint and incident management, performance and outcome data, provider review, and service quality assessments are used to provide a reasonable picture of progress towards outcomes. Input indicators: National Aboriginal and Torres Strait Islander Health Workforce Strategy adopted, and the availability of a skilled health workforce. Performance Indicator Local Performance Indicator target Data source Proposed Activities Output indicators: availability of health workforce; appropriateness response to diverse, remote and rural locations; quality safety, clinical, responsiveness and continuity; sustainability workforce by age group and staff attrition; and efficiency health workforce expenditure per persons care. Outcome measures: increase in Aboriginal and Torres Strait Islander people across all health-related disciplines; enhanced primary health care services; culturally responsive care; reduction in the burden of disease; and improved chronic disease management. Aboriginal Health Worker (AHW) training opportunities number of application received, and number of Aboriginal and Torres Strait Islander people across health-related disciplines within NQPHN s footprint. Reporting timeframes will be quarterly. Internal reporting and monitoring framework. 7

8 Priority Area Activity Title / Reference Description of Activity Collaboration Aboriginal and Torres Strait Islander health, pathways, rural and remote, chronic disease, specialist clinic access, mental health. 1.2 Improving the Indigenous patient journey (New) In NQPHN s footprint, Aboriginal and Torres Strait Islander people commonly experience a complex set of acute or chronic comorbidities requiring hospital interventions. For many patients from rural and remote Indigenous communities, addressing these health circumstances is further complicated by having English as a second or third language and needing to travel long distances to access care, hospital, entering and operating a lift, experiencing unfamiliar languages, food and noises, and dealing with Western medical practices. NQPHN acknowledges that a patient journey is not a care pathway. It does not merely follow a patient through the physical path of medical and social care, but dives deeper into understanding the patient's experience of a condition, and how that experience is created through interactions with other stakeholders, such as healthcare professionals, caregivers and other patients. The aim of this activity will be to develop an alternative model of care for this patient group, based on a clinical/cultural approach and improved communication, and determine whether an alternative model of care enhances patient outcomes and overall hospital efficiencies. NQPHN will be working side-by side with General Practices and Aboriginal Community Controlled Health Services. Duration Anticipated activity in May 2016 and completion date in June Coverage Commissioning approach The geographic coverage of the activity will be the entire NQPHN footprint. NQPHN will procure a provider to undertake this project. NQPHN will conduct ongoing monitoring and evaluation of the contract. Sources such as patient feedback, complaint and incident management, performance and outcome data, provider review, and service quality assessments are used to provide a reasonable picture of progress towards outcomes. NQPHN will seek to understand the potential within the market by firstly advertising to invite Expressions Of Interest. This will allow NQPHN to identify potential providers who may be suitable to deliver the service required. NQPHN will then undertake a competitive Request for Proposal process. From here, NQPHN will execute contracts. 8

9 Monitoring of performance will be conducted based on factors such as the level of risk, value, and impact of the contract. This will be assessed, and will determine the level and frequency of reporting. Specific contract managers within the organisation will be identified and meet regularly with the provider to understand any barriers, opportunities or improvements. Performance Indicator Local Performance Indicator target Data source Proposed Activities Priority Area Activity Title / Reference Description of Activity Performance indicators for improving the patient journey. Output indicators will include: Waiting times for services, selected adverse events in acute and sub-acute care settings, unplanned/unexpected readmissions within 28 days of surgical admissions, and survival of people diagnosed with cancer (five years relative rate). Outcome measures will include: Level of access to health and wellbeing interventions locations of service and level of care; improved referrals; and improving transitions between primary health care and hospital. The local performance indicator target will include: Number of culturally secure health education products and services to give Indigenous people skills and understanding of preventative health and self-management of some chronic health conditions; increase in percentage of Aboriginal and Torres Strait Islander people with chronic disease with a care plan in place; percentage of Aboriginal and Torres Strait Island people participating in rehabilitation programs intended to reduce hospitalisation of people with chronic disease; increase in number of transition care; number of did not attend (DNA) in primary health care and other referral services; quality of Aboriginal and Torres Strait Islander identification in key vitals and administrative datasets. Internal performance measures quarterly Local HHS Emergency Department admissions yearly Pen Cat/Pat Cat General Practice Data quarterly/yearly. Aboriginal and Torres Strait Islander Health, Healthy Behaviours, Mental Health, Drug and Alcohol 1.3 Improving Aboriginal and Torres Strait Islander youth health. (New) In NQPHN s region, building strong and positive cultural identity is important for the health and wellbeing of Aboriginal and Torres Strait Islander youth. They need to be supported through positive role models, and participate in decisions that affect them, their future and their communities. NQPHN has identified through the Health Needs Assessment that Aboriginal and Torres Strait Islander young people do die prematurely due to accidents, suicide, violence, pregnancy related complications, and other illnesses that are 9

10 Collaboration either preventable or treatable. Many more suffer chronic ill-health and disability. In addition, many serious diseases in adulthood have their roots in adolescence. For example, tobacco use, sexually transmitted infections including HIV, and poor eating and exercise habits lead to illness or premature death later in life. NQPHN will create grant opportunities for organisations to apply to develop project/s or programs to create environments for Aboriginal and Torres Strait Islander young people to increase health literacy, make healthy choices, identify and address health issues early, and support sport, music, and art and education aspirations. Objective of the activity Promote school and juvenile justice settings as health promoting institutions; expand and integrate mental health and substance use services particularly for this age group; establish effective and value forming initiatives through peer modelling leadership and engagement with cultural and other valued social institutions; provide appropriate services and facilities for young people in complex needs; and provide and promote physical activity in communities. NQPHN will be working side-by-side with General Practices, and Aboriginal Community Controlled Health Services. Duration Anticipated activity in May 2016 and completion date in June Coverage Commissioning approach The geographic coverage of the activity will be the entire NQPHN footprint. NQPHN will create grant opportunities for organisations, and a contract will be developed with local key performance indicators, based on the Health Needs Assessment. NQPHN will conduct ongoing monitoring and evaluation of the contract. Sources such as patient feedback, complaint and incident management, performance and outcome data, provider review, and service quality assessments are used to provide a reasonable picture of progress towards outcomes. NQPHN will seek to understand the potential within the market by firstly advertising to invite Expressions Of Interest. This will allow NQPHN to identify potential providers who may be suitable to deliver the service required. NQPHN will then undertake a competitive Request for Proposal process. From here, NQPHN will execute contracts. Monitoring of performance will be conducted based on factors such as the level of risk, value, and impact of the contract. This will be assessed, and will determine the level and frequency of reporting. Specific contract managers within the organisation will be identified and meet regularly with the provider to understand any barriers, opportunities or improvements. 10

11 Performance Indicator Local Performance Indicator target Data source Proposed Activities Priority Area Activity Title / Reference Description of Activity Input indicators: Implementation Plan for National Aboriginal and Torres Strait Islander Health Plan Output indicators: Availability of regional youth health program; appropriateness response to diverse, remote and rural locations; focus on prevention; quality safety, clinical, responsiveness, and continuity; sustainability workforce by age group, and staff attrition; and efficiency care expenditure per person, patient-centred, sustainable, and equity. Connecting with the community engagement activities. 1. Number of additional health professionals (youth-focused) 2. Hospital separation rates for injury including force and violence (15-24yrs) 3. Internal performance measures will be utilised and reported on using the normal reporting mechanisms 4. Rate of sexually transmissible infections 5. Excess mortality and morbidity among Aboriginal and Torres Strait Islander men 6. Homicide death rate by Aboriginal and Torres Strait Islander people (15-24yrs). 1. Internal auditing of contracted services quarterly/yearly 2. Local Hospital and Health service data quarterly/yearly 3. Internal reporting mechanisms quarterly/yearly 4. Tropical Public Health Unit data quarterly/yearly 5. National Health Performance Authority yearly. Aboriginal and Torres Strait Islander health, maternal and child, healthy behaviours, substance misuse (drugs and alcohol), community chronic disease management, rural and remote health care access, and HealthPathways. 1.4 Blood Borne Viruses and Sexually Transmissible Infections Prevention Program. (New) In NQPHN s region, Aboriginal and Torres Strait Islander people experience poorer health outcomes than other Australians, including in the area of sexual health. Aboriginal and Torres Strait Islander people have substantially higher rates of sexually transmissible infections (STIs), blood borne viruses (BBVs) and teen pregnancy than non-indigenous Australians, particularly for chlamydia, gonorrhoea, infectious syphilis, hepatitis B and hepatitis C. 11

12 Sexual health education programs are one way of promoting sexual health for Aboriginal and Torres Strait Islander people. They are typically social and behavioural interventions that try to reduce the risk of exposure to the individual and community by using strategies such as counselling, education, health promotion activities, and community development activities. NQPHN will commission a service to develop the following activities - capacity and capability of Aboriginal Community Controlled Health Services to deliver coordinated outreach services such as opportunistic testing for STIs including HIV, chlamydia, gonorrhoea, trichomonas and infectious syphilis, provision of community education on BBV and STI to encourage safer sexual health and drug injecting practices, and deliver BBV education to Aboriginal and/or Torres Strait Islander communities to increase awareness of viral hepatitis, improve drug injection practices, reduce stigma associated with drug use, and promote harm reduction strategies with support from communities and elders. Collaboration NQPHN will be working side-by side with General Practices, and Aboriginal Community Controlled Health Services. Blood borne viruses and sexually transmissible infections have been identified as a very high priority in some communities in the NQPHN region. It has also been identified in NQPHNs health needs assessment. NQPHN is aware of existing services delivered by the State and Commonwealth Governments and will not duplicate activities. The approach will be to dovetail activities with partners thereby synergistically strengthening an integrated and joined-up patient journey leading to improved outcomes. Duration Anticipated activity in May 2016 and completion date in May Coverage Commissioning approach The geographic coverage of the activity will be the entire NQPHN footprint. NQPHN will commission a service to provide sexual health promotion/education and outreach services to remote and rural communities. NQPHN will conduct ongoing monitoring and evaluation of the contract. Sources such as patient feedback, complaint and incident management, performance and outcome data, provider review, and service quality assessments will be used to provide a reasonable picture of progress towards outcomes. NQPHN will seek to understand the potential within the market by firstly advertising to invite Expressions Of Interest. This will allow NQPHN to identify potential providers who may be suitable to deliver the service required. NQPHN will then undertake a competitive Request for Proposal process. From here, NQPHN will execute contracts. 12

13 Monitoring of performance will be conducted based on factors such as the level of risk, value, and impact of the contract. This will be assessed, and will determine the level and frequency of reporting. Specific contract managers within the organisation will be identified and meet regularly with the provider to understand any barriers, opportunities or improvements. Performance Indicator Local Performance Indicator target Data source Input indicators: Implementation Plan for National Aboriginal and Torres Strait Islander Health Plan Output indicators will include: Availability of regional sexual health programs; appropriateness response to diverse, remote and rural locations; focus on prevention; quality safety, clinical, responsiveness, and continuity; sustainability workforce by age group, staff attrition; and efficiency care expenditure per person, patient-centred, sustainable, and equity. Connecting with the community engagement activities. Reduced spread of BBVs and STIs and increased uptake of testing and treatment; reduced barriers to accessing healthcare; and increased uptake of testing and treatment for BBVs and STIs in Aboriginal and Torres Strait Islander communities living in regional and remote areas. 1. Tropical Public Health Unit data quarterly/yearly 2. Pen Cat/Pat Cat General Practice Data quarterly/yearly 13

14 2. Maternal and Child Health The objectives of NQPHN s involvement in maternal and child health are: Improve access to sexual and reproductive health services Improve access to health promotion programs before and during pregnancy Affordable access for mothers and fathers for high-quality antenatal and postnatal services Improve mothers, fathers and carers access to positive parenting information and support services Ensure that children are in good health and meet key development milestones, laying the foundation for long healthy lives Improve access to child health services that are evidence-based, early health diagnosis, and coordinated and quality treatment services. In and onwards, NQPHN will: Implement innovative and locally-tailored solutions through maternal and child health programs/services, based on community need Work to address gaps in maternal and child health service provision, particularly in rural and remote communities within NQPHN. Proposed Activities Priority Area Activity Title / Reference Description of Activity Maternal and Child Health, Substance Misuse, Aboriginal and Torres Strait Islander Health, Rural and Remote, Healthy Behaviours. 2.1 Access to health promotion programs before and during pregnancy (smoking cessation, FASD). (New) Delivery of smoking cessation and foetal alcohol syndrome disorder health promotion program before and during pregnancy initiatives arose from the NQPHN Health Needs Assessment, which identified high rates of smoking during pregnancy in NQPHN s region, with Townsville and Mackay regions estimated at 19.5 per cent of pregnant women smoking, and Cairns and Hinterland and Torres Strait and Cape regions at 27.3 per cent of pregnant women smoking. 14

15 Collaboration NQPHN acknowledges that smoking and drinking excess alcohol, poor nutrition and other lifestyle factors can lead to poor outcomes for mothers and babies. The provision of routine health promotion (including advice and education and sometimes screening tests) before conception may encourage changes to improve health, and may be an opportunity to identify risk factors such as infection that can be treated before pregnancy begins. NQPHN will create grant opportunities for the delivery of smoking cessation and foetal alcohol syndrome disorder health promotion programs to both mothers and fathers to encourage healthy pregnancy, which will lead to improved health and wellbeing for mothers and babies. The objectives will be to increase mother and father awareness of the effect of smoking cessation and alcohol before and during pregnancy, and improve preconception health, which can lead to improved reproductive health outcomes. The activity will promote awareness of cessation and effect of alcohol during pregnancy, provide smoking cessation training to health providers, and promote cessation service integration aimed at improving birth outcomes. NQPHN will be working side-by-side with mainstream service providers, general practice clinics, Aboriginal Community Controlled Health Services, and HHS delivery effective smoking cessation and FASD health promotion. Smoking and alcohol consumption before and during pregnancy have been identified as a very high priority in some communities in NQPHN. It has also been identified in NQPHNs health needs assessment. NQPHN is aware of existing services delivered by the State and Commonwealth Governments and will not duplicate activities. NQPHN s approach will be to dovetail activities with partners thereby synergistically strengthening an integrated and joined-up patient journey leading to improved outcomes. Duration Anticipated activity in May 2016 and completion date in June Coverage Commissioning approach The geographic coverage of the activity will be the entire NQPHN footprint. NQPHN will create grant opportunities for organisations to apply for funding to deliver smoking cessation and foetal alcohol syndrome disorder health promotion activities. NQPHN will conduct ongoing monitoring and evaluation of the contract. Sources such as patient feedback, complaint and incident management, performance and outcome data, provider review, and service quality assessments are used to provide a reasonable picture of progress towards outcomes. Maternal and child health is a key priority for NQPHN, with development and delivery informed by six commissioning cycle stages: Review strategic alignment, including with the Department of Health, Health Workforce Australian Framework Review needs assessment based on NQPHN Health Needs Assessment/locally identified need/provider surveys 15

16 Performance Indicator Local Performance Indicator target Data source Plan Workforce Development Program Design Workforce Development Program Procure external services as identified Monitor and evaluate. NQPHN will seek to understand the potential within the market by firstly advertising to invite Expressions Of Interest. This will allow NQPHN to identify potential providers who may be suitable to deliver the service required. NQPHN will then undertake a competitive Request for Proposal process. From here, NQPHN will execute contracts. Monitoring of performance will be conducted based on factors such as the level of risk, value, and impact of the contract. This will be assessed, and will determine the level and frequency of reporting. Specific contract managers within the organisation will be identified and meet regularly with the provider to understand any barriers, opportunities or improvements. Output indicators will include: Number and key results of patient and community education/health promotion to promote quitting smoking and FASD; brief interventions, other smoking cessation and FASD education and support offered to individuals; evidence of implementation of regulatory efforts to encourage reduction/cessation in individuals and communities; number of service delivery staff trained to deliver smoking cessation and FASD education/interventions. Outcome measures will include: incidence/prevalence of important preventable diseases and injury; proportion of babies born of low birth weight; teenage birth rate; risk factor prevalence; immunisation rates for vaccines; cancer screening rates; and number of women with at least one antenatal visit in the first trimester of pregnancy; tobacco smoking during pregnancy; social-emotional wellbeing and health promotion. Expression of Interest process subcontracted provider in place following EOI process; sessions number of sessions delivered (individual or group); occasions of service target group, gender, age; referrals number of new referrals, number referrals resulting in session, average number of sessions per referrals, and referral source; satisfaction perception rating via patient opinion improving wellbeing, and feeling supported; Aboriginal and Torres Strait Islander community outcomes measures (ethnicity of clients receiving services); target Aboriginal and Torres Strait Islander population receiving services greater or equal to the population profile. Reporting timeframes will be quarterly. 1. Australian Immunisation Childhood Register quarterly/yearly 2. Queensland Preventative Health Survey 13/14 (December 2015) 3. Local Hospital and Health Service data on birth weight 4. Patient Opinion feedback quarterly/yearly 16

17 Proposed Activities Priority Area Activity Title / Reference Description of Activity Collaboration Maternal and Child Health, Mapping, Rural and Remote, Specialist Access, Aboriginal and Torres Strait Islander Health, Healthy behaviours 2.2 Increased engagement in maternal and child health services (New) Infants born at full term, within the normal weight ranges, to a mother in good health, is a major contributor to good health and wellbeing outcomes in childhood and adult life. Childhood illness and chronic disease predisposes to adult poor health outcomes. NQPHN reports that 6.6 per cent of babies are born low birth rate (< 2.5kg), which is higher than that reported nationally at 6.2 per cent, and more low-birth weight babies are born to Aboriginal and Torres Strait Islander mothers, with 22 per cent of all babies from Hope Vale and 21 per cent from Palm Island, compared to 8 per cent in Queensland. Providing access to appropriate and quality care in the antenatal and postnatal period is a key perinatal outcome. It also offers an important opportunity to ameliorate disease in adult life, given the recognised link between early life influences and chronic disease. NQPHN will coordinate and support antenatal and postnatal child health services from both general practices, Aboriginal Community Controlled Health Services, and HHSs through a shared collaborative model of care. The objective of the activity will be to facilitate the provision of a community-based collaborative model of antenatal and post-natal service in regional, rural and remote communities of NQPHN, where gaps in delivery are identified; facilitate linkages with General Practices, Aboriginal Community Controlled Health Services and HHSs of the delivery of service provision, and promote a coordinated, multidisciplinary team-based approach to the provision of integrated antenatal care and postnatal services. This activity incorporates a focus on mapping services to better determine service access gaps and priorities, and support improved referral and coordination of care; consider transport needs specific to maternal and child health and determine strategies to target the better use of existing transport resources; and commission services for rural and remote communities to support maternal and child health, including allied health and medical specialists. NQPHN will be working side-by side with General Practices, Aboriginal Community Controlled Health Services, and HHSs. Duration Anticipated activity in May 2016 and completion date in June Coverage Commissioning approach The geographic coverage of the activity will be the entire NQPHN footprint NQPHN will employ a Maternal and Child Health Lead and three Regional Coordinators to: Ensure the Maternal and Child Health Service is informed through robust planning, including planning for service development opportunities, staffing and the enhancement of service quality to ensure adequate services are delivered now and into the future; 17

18 Performance Indicator Local Performance Indicator target ensure effective planning of the maternal and child health service; provide vision and future planning to assist communities to recognise health needs and to implement actions, which will enhance the wellbeing of the community; maintain effective working relationships with government, peak bodies, medical and health services, local service providers, and other agencies; provide forums relating to children and families; develop and maintain partnerships with internal and external stakeholders to bring together initiatives and actions; communicate appropriate information to clients and community services/organisations regarding the maternal and child health services; participate in community education/health promotion programs where relevant; facilitate the development of community support networks through partnerships with other services and organisations; and conduct research (i.e. surveys and community consultation) to ascertain community needs, both short and long term, and customer satisfaction regarding service delivery. NQPHN will conduct ongoing monitoring and evaluation of the contract. Sources such as patient feedback, complaint and incident management, performance and outcome data, provider review, and service quality assessments are used to provide a reasonable picture of progress towards outcomes. NQPHN will seek to engage with the market in a competitive dialogue, or interactive procurement approach, to ensure that the service solution purchased and implemented meets the needs of the community. This process will be particularly valuable in enabling innovation. This approach will be completed with the release of a competitive approach to market resulting a contract execution. Monitoring of performance will be conducted based on factors such as the level of risk, value, and impact of the contract. This will be assessed, and will determine the level and frequency of reporting. Specific contract managers within the organisation will be identified and meet regularly with the provider to understand any barriers, opportunities or improvements. Input indicators: National Guidelines for Antenatal and Postnatal Services adopted; the availability of skilled health workforce. Output indicators: Availability of antenatal and postnatal services; appropriateness response to diverse, remote and rural locations; quality safety, clinical, responsiveness, and continuity; sustainability workforce by age group and staff attrition; and efficiency care expenditure per person. Outcome measures: Level of access to antenatal and postnatal services; proportion of pregnant women satisfied with services they received; increased proportion of pregnant women with an antenatal contact in the first trimester of pregnancy in each year; reduced proportion of babies born with low birth weight each year; reduced mortality of rate infants each year; reduced proportion of women who use substances during pregnancy each year; and reduced proportion of hospital admissions of children 0-4 years. GP referrals number of referrals received, and number of GPs referring to antenatal and postnatal service; client numbers number of clients who have received care; average number of sessions per client; Aboriginal and Torres Strait Islander community (discrete, rural and remote) receiving services; target Aboriginal and Torres Strait Islander population receiving services greater than or equal 18

19 Data source Proposed Activities Priority Area Activity Title / Reference to the population profile; occasions of service number and location of coordination services funded by the program; type of service - types of service delivery of models, number of and type of service supported. Reporting timeframes will be quarterly. 1. National Key Performance Indicator immunisation, quarterly/yearly 2. Infant mortality rate National Performance Authority - quarterly/yearly 3. Hospital admissions Local HHS yearly 4. Smoking during pregnancy Preventative Health Survey results 13/14 (Dec 2015) yearly 5. Pen Cat/Pat Cat General Practice data. Maternal and Child Health, Rural and Remote, Aboriginal and Torres Strait Islander Health, mental health, Substance Misuse. 2.3 Family Specialist Programs Indigenous Triple P program. An alternative model may be required for specific groups. (New) Description of Activity Collaboration Family Specialist Programs arose from the NQPHN Health Needs Assessment which identified large gaps in childhood milestones. Triple P Positive Parenting Program is a world-renowned program that helps to make raising children and teenagers easier. NQPHN will procure a provider to deliver the Indigenous Triple P program within the Cape and Torres, which will increase parent confidence, self-esteem, and capability to effectively monitor and appropriately address children s behaviour; increase parent awareness and knowledge of social, emotional and behavioural problem children; increase parent knowledge of enhancing relationships. NQPHN will be working side-by-side with General Practices, and Aboriginal Community Controlled Health Services to enhance Cape and Torres in addressing growth and development of children, positive parenting that lead to best possible care and support for good start to life. The Triple P program as funded and delivered under Queensland Health does not currently offer Indigenous Triple P in the Cape and Torres region the NQPHN footprint. NQPHN will engage Aboriginal Medical Services to specifically design and deliver an Indigenous Triple P program, which will dovetail with the existing standard State Triple P program. Duration Anticipated activity in May 2016 and completion date in June Coverage The geographic coverage of the activity will only be the Cape and Torres region. 19

20 Commissioning approach Performance Indicator NQPHN will tender for an Indigenous Triple P provider to delivery sessions across Cape and Torres region Indigenous Triple P Indigenous Triple P allows providers accredited in Primary Care, Group and/or Standard Triple P programs to tailor their delivery of the programs to suit Indigenous families. Materials and content for Indigenous Triple P were created in consultation with elders from remote and urban Indigenous communities in Australia. Indigenous Triple P has been used with both Indigenous Australian families and aboriginal Canadian families. NQPHN will conduct ongoing monitoring and evaluation of the contract. Sources such as patient feedback, complaint and incident management, performance and outcome data, provider review and service quality assessments are used to provide a reasonable picture of progress towards outcomes. NQPHN will seek to understand the potential within the market by firstly advertising to invite Expressions Of Interest. This will allow NQPHN to identify potential providers who may be suitable to deliver the service required. NQPHN will then undertake a competitive Request for Proposal process. From here, NQPHN will execute contracts. Monitoring of performance will be conducted based on factors such as the level of risk, value, and impact of the contract. This will be assessed, and will determine the level and frequency of reporting. Specific contract managers within the organisation will be identified and meet regularly with the provider to understand any barriers, opportunities or improvements. Input indicators: Indigenous Triple P Program Guidelines; Enhanced maternal and child health skilled workforce in Cape and Torres region; Promote awareness and use of the Australian Early Development Index to support the development of evidence informed strategies, policies and programs, and support communities to consider what they can do to better support children and their families; Improved Aboriginal health partnership forums with states and territories will consider the incorporation of parenting program in their respective action plans Output indicators will include: Availability of Indigenous Triple P in Cape and Torres region; positive parenting, Outcome measures will include: Participation rate of in Indigenous Triple P Program, Rates of Immunization among Aboriginal and Torres Strait Islander families, Access to website materials (e.g. Raising Children Network) that provide culturally appropriate information to Aboriginal and Torres Strait Islander families; no. of health checks for Indigenous children before starting school. Local Performance Indicator target The local performance indicator target will include: 20

21 Parenting program location of program delivered; number of parenting programs delivered; number of parents number of participants that partake in the parenting programs; and pre- and post-satisfaction perception rating via survey. Reporting timeframes will be quarterly. Data source 1. Program specific outcome measures per program/complete evaluation 21

22 3. Chronic Disease Management Thirty-five per cent of Australian (over 7 million) 1 people have a chronic condition, with an increasing number having multiple morbidities increasing the need for improved coordination of care. Patients with chronic disease are high users of health care services, including preventable hospitalisations. As a result of the increasing complexity of care needs, NQPHN will co-design and implement collaborative programs that support general practice as the patient s medical home. NQPHN develops and deliver chronic disease management initiatives that are: Person centred and family orientated Sustainable and feasible Flexible Culturally safe and equitable Integrated and fragmentation reducing team-based care Accountable and measurable Supportive of flexible models of care Consider and adopt new models of care and/or emerging health reforms. Rural and remote communities are at particular disadvantage in regards to specialist and allied health professional access. Considered the most disadvantaged are many regional, rural, remote and Aboriginal and Torres Strait Islander communities which face considerable barriers both geographically and culturally to accessing specialist medical and allied health services. It is critically important to improve access to specialist and allied health providers services for regional, rural, remote and Aboriginal and Torres Strait Islander peoples and communities, and is a major consideration when developing and maintaining access to services. NQPHN aims to design initiatives that improve access to specialist services in regional, rural and remote communities utilising partnerships and co-design supported by new and emerging technologies. Initiatives are prioritised based on community need identified in the NQPHN Health Needs Assessment. Initiatives will target improved access to public and private specialists, as well as Indigenous and non-indigenous allied health services with strong linkages to primary care providers. 1 Australian Primary Health Care Advisory Group, 2015, Better Outcomes for people with Chronic and Complex Health Conditions 22

23 Proposed Activities Priority Area Activity Title Description of Activity Chronic Disease Management, Rural and Remote, Mapping, Specialist Access, Transport, Promote Positive Health Behaviours, Pathways, Aged Care, Aboriginal and Torres Strait Islander Health, My Health Record, Workforce, After Hours, Mental Health, Health Transport Services. 3.1 Chronic Disease Management (Project 1-4 are new, with the exception of Telehealth. Project 5 is Continuing service) 1. Project 1 - Design and implement evidence-based general practice lead/medical home model chronic disease management initiatives that: Utilise Medicare Benefits Schedule (MBS) chronic disease billing and management pathways Employs HealthPathways to ensure patients receive the right care, at the right time, in the right place Promotes the use of My Health Record, telehealth and other technologies that enhance the patient journey. Support the implementation of the Better Outcomes for people with Chronic and Complex Health Conditions (Report of the primary health care advisory group) recommendations 2. Project 2 - Build primary care providers capacity to adopt and implement evidence-based models of care, and establish new and emerging: Nurse-led Clinics Medical Assistants Indigenous Health Workers Telehealth in practice. 3. Project 3 - Develop and deliver support mechanisms to improve consumer self-management Patient information Patient service provider directories Health literacy capacity-building activities. 4. Project 4 - Map services to better determine service access gaps and priorities, and support improved referral and coordination of care. Consider transport needs of people with chronic disease and determine strategies to target the better use of existing transport resources. 23

24 5. Project 5 - Commission services for rural and remote communities to support multidisciplinary, comprehensive primary health care, including allied health and medical specialists. Collaboration To ensure a comprehensive approach to Chronic and Complex Condition Care Management, NQPHN will need to maintain high level formal and informal collaborative relationships with multiple stakeholders including (but not limited to): Health and Hospital Services (Formal: Charter Directed Partnership) Primary care providers Aboriginal and Torres Strait Islanders Medical Services (Formal: MOU) Private and public sector specialist and hospitals Allied health care providers Residential Aged Care Facilities State and national telehealth agencies Duration Anticipated activity reporting period from 1 July 2016 to 30 June Coverage Commissioning approach The geographic coverage of these interventions and activities will be the entire NQPHN footprint. Chronic and Complex Condition Care Management is a key priority for NQPHN, with development and delivery informed by six commissioning cycle stages: Review strategic alignment, including with the Department of Health, Health Workforce Australian Framework Review needs assessment based on NQPHN Health Needs Assessment/locally identified need/provider surveys Plan Workforce Development Program Design Workforce Development Program Procure external services as identified Monitor and evaluate. Projects 1, 2 & 4 NQPHN will seek to understand the potential within the market by firstly advertising to invite Expressions Of Interest. This will allow NQPHN to identify potential providers who may be suitable to deliver the service required. NQPHN will then undertake a competitive Request for Proposal process. From here, NQPHN will execute contracts. 24

25 Performance Indicator Monitoring of performance will be conducted based on factors such as the level of risk, value, and impact of the contract. This will be assessed, and will determine the level and frequency of reporting. Specific contract managers within the organisation will be identified and meet regularly with the provider to understand any barriers, opportunities or improvements. Project 3 NQPHN will directly approach the most capable provider, ensuring that all due diligence and required governance arrangements and a suitable and efficient model are in place. At the time of this approach, if there is an indication that there may be other suitable providers, then NQPHN will firstly advertise to invite Expressions Of Interest. Monitoring of performance will be conducted based on factors such as the level of risk, value, and impact of the contract. This will be assessed, and will determine the level and frequency of reporting. Specific contract managers within the organisation will be identified and meet regularly with the provider to understand any barriers, opportunities or improvements. Project 5 Within , the existing programs that are being commissioned or transitioned from the Department of Health to NQPHN will be continued for a further 6-12 months. During this period of time, NQPHN will review each of the programs against the criteria identified in the performance evaluation framework being developed, as well as the new service models being scoped. Following the review, NQPHN will work with the commissioned services to identify service improvements and potential collaborations/partnerships that may enhance program outcomes. With any new services, NQPHN will seek to engage with the market in a competitive dialogue, or interactive procurement approach, to ensure that the service solution purchased and implemented meets the needs of the community. This process will be particularly valuable in enabling innovation. This approach will be completed with the release of a competitive approach to market resulting a contract execution. Monitoring of performance will be conducted based on factors such as the level of risk, value, and impact of the contract. This will be assessed, and will determine the level and frequency of reporting. Specific contract managers within the organisation will be identified and meet regularly with the provider to understand any barriers, opportunities or improvements. Output indicators will include: Project 1 Number of HealthPathways developed Number of telehealth locations. 25

26 Project 2 New innovative models of care Indigenous Health Workers skilled. Project 3 Number of health literacy workshops delivered Self-care resources developed and used by consumers. Project 4 Number of services mapped and validated Production of heat maps and data to support commissioning. Project 5 Number and type of Access Initiatives i.e. specialist; allied health; clinics facilitated by NQPHN Number and type of allied health sessions provided to rural and remote communities Number and type of services accessed via telehealth Number and location of teleconferencing licences provided to health care providers. Outcome measures will include: Project 1 - Reduction in preventable hospital admissions, and reduced waiting times Project 2 - Reduction in preventable hospital admissions, and increased GP access for Aboriginal and Torres Strait Islander people Project 3 - Reduction in Preventable hospital admissions, improved self-care Project 4 - Reduction in Preventable hospital admissions; currency of National Health Services Directory, and improved awareness and navigation of services by consumers and providers Project 5 - Improved access to allied health services for consumers in regional, rural and remote communities; improved access to specialist services for consumers in regional, rural and remote communities; enhanced access to telehealth technologies across the NQPHN footprint. 26

27 Local Performance Indicator target Number of general practices being support by the Medical Home Model of Care for Chronic Disease: Number and location of rural telehealth hubs, facilitated in the NPQHN footprint Number and type of telehealth consultations delivered via the rural telehealth hubs Number and type of support services provided. Increased access to comprehensive provider directories for health professionals and consumers. Data source Local HHS ED and potentially preventable hospital admissions and presentations MBS billing data NQPHN Commissioning Contract Reporting data Pen Cat/Pat Cat General Practice data. 27

28 4. Aged Care Proposed Activities Priority Area Activity Title / Reference Description of Activity Collaboration Aged Care 4.1 Aged Care Primary Health Care Reform Readiness (Continuing) There are currently many changes and reforms occurring within the primary health care, general practice, and National Disability Insurance Scheme and aged care space, including the NQPHN being the pioneering site for My Health Record and the progressive functionality of the Commonwealth s My Aged Care portal. NQPHN will invest in one Aged Care Lead and two Aged Care Coordinators to support the delivery of all aged care activities. During this time, general practices need to be supported in these changes. Proposed activities by the Aged Care Portfolio team include: Provide support through the dissemination of information, resources and updates to general practices Provide support through education sessions to general practices Assist with change facilitation in general practices with processes and the care of residents within residential aged care facilities e.g. My Health Record, Advance Care Planning, HealthPathways, etc. Work internally with other NQPHN portfolios including the Practice Support team and My Health Record team. External collaboration with the Department of Health Townsville regional office, Health Pathway teams, Aged Care Assessment Teams, Council on the Ageing and Alzheimer s Australia. Duration From July 2016 to June Coverage Commissioning approach Performance Indicator The geographic coverage of the activity will be the entire NQPHN footprint. N/A - this is a system-wide reform enabling activity delivered by the Aged Care Portfolio team. Output indicators will include: Promote changes and reforms through NQPHN newsletter Number of information events conducted 28

29 Number of participants attending information events Number of general practices who have received information Increased number of people accessing aged care information on HealthPathways sites Evaluation of events. Outcome measures: Increased use of Aged Care HealthPathways Seamless transition through the aged care sector for all users. Local Performance Indicator target Data source Proposed Activities Priority Area Activity Title / Reference Description of Activity Number of general practices being supported by NQPHN. Workshop registrations, attendance lists and evaluations. Aged Care 4.2 Advance Care Planning (New) Assisting the Townsville, Mackay, Cairns and Hinterland, and Cape and Torres Hospital and Health Services fulfil the roll-out of the Queensland state-wide End of Life Strategy within the primary health care sector. Primarily activities will have an educational focus to build capacity for primary healthcare providers and aged care services in providing end of life care to clients, including advance care planning and palliative care. Activities may include: Promoting existing advance care planning and palliative care events and activities to primary health care providers and aged care providers Distributing relevant advance care planning and palliative care information, resources and updates to primary health care providers and aged care providers Providing education events to primary health care providers and aged care services on advance care planning and palliative care approaches Providing support and information to primary health care providers and aged care providers around advance care planning documents and identifying clients most appropriate to start advance care planning with Identifying advance care planning processes within residential aged care facilities 29

30 Collaboration Providing support and guidance to residential aged care facilities who do not already have advance care planning processes in place. Internally, working in collaboration with NQPHN portfolio teams such as Practice Support and Workforce Development. In addition, these activities will occur in collaboration with the HHSs and external organisations such as Decision Assist and Program of Experience in the Palliative Approach (PEPA) in which their educational expertise may be utilised. Duration From July 2016 to June Coverage Commissioning approach Performance Indicator Local Performance Indicator target Data source Proposed Activities Priority Area Activity Title / Reference The geographic coverage of the activity will be the entire NQPHN footprint. NQPHN will directly approach the most capable provider, ensuring that all due diligence and required governance arrangements and a suitable and efficient model are in place. At the time of this approach, if there is an indication that there may be other suitable providers, then NQPHN will firstly advertise to invite Expressions Of Interest. Monitoring of performance will be conducted based on factors such as the level of risk, value, and impact of the contract. This will be assessed, and will determine the level and frequency of reporting. Specific contract managers within the organisation will be identified and meet regularly with the provider to understand any barriers, opportunities or improvements. Performance indicators for advance care planning: As above. Aged Care Number of education events conducted Number of attendees (including break down by professions) Increased knowledge and confidence in: identifying appropriate patients to start advance care planning discussions with; advance care planning documentation; and ability to complete appropriate advance care planning documents Increase in number of residential aged care facilities with an advance care planning process in place. Workshop registrations and/or attendance sheets Evaluation sheets. 4.3 Digital Health readiness in aged care (New) 30

31 Description of Activity Collaboration Assist residential aged care facilities in the meaningful use of My Health Record. The Aged Care team will work collaboratively with the My Health Record team to educate, support and promote My Health Record in residential aged care facilities and to the aged population within the NQPHN footprint. Proposed activities include: Promote My Health Record events and activities to residential aged care facilities and aged care providers Distribute relevant My Health Record information, resources and updates to residential aged rare facilities and aged care providers Identify My Health Record processes within residential aged care facilities Provide support and guidance to residential aged care facilities who are not using My Health Record Provide information and resources to aged consumers about the My Health Record. My Health Record Team Duration From July 2016 to June Coverage Commissioning approach Performance Indicator Local Performance Indicator target Data source Proposed Activities Priority Area Activity Title / Reference The geographic coverage of the activity will be the entire NQPHN footprint. Direct delivery by NQPHN. Aged Care Number of Aged Care facilities who have received information on My Health Record Number of RACF and Aged Care provider staff that have attended my Health Record training Number of visits to RACFs and Aged Care providers to discuss and support My Health Record. Satisfaction of support Increased use of My Health Record. Workshop registrations and/or attendance sheets Evaluation sheets. Percent of population registered with a My Heath Record. 4.4 Health and Hospital Health Services Innovation Support Integrated Care Innovation Fund (ICIF) OPEN ARCH Older Persons Enablement And Rehabilitation for Complex Health Conditions (New) 31

32 Description of Activity Collaboration The overarching purpose of the project is to provide system navigation that facilitates seamless service integration across the Cairns and Hinterland Hospital and Health Service and, in doing so, reduces fragmentation of care for people with chronic conditions and complex health needs living in the community. The proposed intervention is targeted and focused, and will deliver better health care for the community through systemised integration of primary and secondary care: The project will aim to prioritise people in the community with complex conditions at risk of either hospital admission or further deterioration in their health The General Practitioner is integral to this project by identifying those at risk through timely interventions and appropriate care planning, referral pathways, and community service support The model of care will ensure people with complex conditions access appropriate and early intervention, with access to specialised geriatrician assessment and/or rehabilitation support and restorative care The Primary Health Care Integration Clinician (PHIC) is central to the model of care through care plan coordination, liaison with stakeholders, and referral to appropriate pathways and community services The patient remains the focus of the integrated model of care with wrap-around services that will promote patient autonomy, self-care, and enablement in the management of their health. The PHN Aged Care portfolio will support OPEN ARCH by: Recruiting and inducting up to five General Practices to serve as beacon practices for the initiative Working with the NQPHN Practice Support team to provide intensive and tailored supports to beacon practices to ensure that they can participate in the initiative Participating in project governance meetings Supporting the Primary Health Care Integration Clinician role, which is to be piloted as part of the initiative. Cairns and Hinterland Hospital and Health Service Principal Project Lead Associate Professor Edward Strivens (CHHHS) Geriatrician hot clinic in specific General Practices (CHHHS) Short term and restorative allied health care team (CHHHS) Nominated General Practitioners with cohort of community with complex health conditions Primary Health Care Integration Clinician (NQPHN) Nurse Navigators (CHHHS) Community service stakeholders. 32

33 Duration From July 2016 to June Coverage Commissioning approach Performance Indicator Local Performance Indicator target Data source The geographic coverage of the activity will be the Cairns and Hinterland Hospital and Health Service area. Innovation pilot in partnership with Cairns and Hinterland Hospital and Health Service NQPHN will seek to understand the potential within the market by firstly advertising to invite Expressions Of Interest. This will allow NQPHN to identify potential providers who may be suitable to deliver the service required. NQPHN will then undertake a competitive Request for Proposal process. From here, NQPHN will execute contracts. Monitoring of performance will be conducted based on factors such as the level of risk, value, and impact of the contract. This will be assessed, and will determine the level and frequency of reporting. Specific contract managers within the organisation will be identified and meet regularly with the provider to understand any barriers, opportunities or improvements. Number of referrals of people with complex conditions to General Practitioners Number of referrals/appointments with the Primary Health Integration Clinician (PHIC) Number of referrals/appointment with Community Geriatrician General Practitioner Care plan completion General Practitioners increased confidence and knowledge in managing complex conditions in the community Changes in the management of complex older people in the community Change in consumer self-management capacity Improved functional and quality of life measures of people with complex health conditions. Reduced number of Emergency Department representations for the enrolled patient cohort Reduced number of Emergency Department admissions for the enrolled patient cohort Reduced number of days in hospital for the enrolled patient cohort Change in diagnosis related groups (DRG) admission trends Improved patient experiences and satisfaction. Data will be extracted from HHS clinical activity data sources by requesting case mix reports for: Emergency Department presentations from Firstnet which links to iemr, the digital patient record Hospital admissions via Emergency Department from Hospital Based Corporate Information System (HBCIS) Hospital in-patient bed days from the Hospital Based Corporate Information System (HBCIS) 33

34 Proposed Activities Priority Area Activity Title / Reference Description of Activity Aged Care 4.5 Health and Hospital Health Services Innovation Support Integrated Care Innovation Fund (ICIF) Mackay Integrated Aged Care Initiative (MIACI) (New) The innovation project includes a collaboration with Mackay Hospital and Health Service, Northern Queensland Primary Health Network, Queensland Ambulance Service, three General Practices, three Residential Aged Care Facilities (RACFs), and a private consultant pharmacist to work together to support residents with low acuity condition to be managed within local RACFs. This initiative proposes to: 1. Improve continuity of care and seamless transition between care settings by developing interagency partnerships and collaborative care planning 2. Provide clinical support to RACF staff in managing unwell residents to avoid transfer to ED 3. Replicate existing emergency model of telehealth to support RACFs and GPs in care for unwell residents 4. Establish electronic connectivity through secure transmission of clinical handover information 5. Provide transport of RACF residents by QAS to GP practices for clinical assessment or intervention 6. Develop agreed Aged Care HealthPathways and access to Mackay Health Pathway site 7. Promote the shared record (clinical summary and advanced care plans) through use of My Health Record 8. Development of education support programs for RACFs 9. Create an electronic transfer of discharge medication plans to RACFs and local pharmacies. The PHN Aged Care Portfolio will support MIACI by: Recruiting and inducting up to three General Practices to serve as beacon practices for the initiative Recruiting and inducting up to three RACFs to participate in the initiative Working with the PHN Practice Support team to provide intensive and tailored supports to beacon practices to ensure that they can participate in the initiative Working with the PHN Telehealth Coordinator to facilitate clinicians to use tele-consultations Working with the PHN My Health Record team to encourage the use of My Health Record in tandem with tele-consultations Facilitating project governance meetings - HHSs, General Practices, RACF, Queensland Ambulance Service, etc. 34

35 Collaboration Mackay Hospital and Health Service Good Shepherd Lodge Resthaven on Quarry Sarina Aged Residential Home Inc. Queensland Ambulance Service Mackay community pharmacy Plaza Medical Practice AWAL Medical Centre Southside Medical Service. Duration From July 2016 to June Coverage Commissioning approach Performance Indicator The geographic coverage of the activity will be the Mackay Hospital and Health Service area. Innovation pilot in partnership with Mackay Hospital and Health Service NQPHN will seek to understand the potential within the market by firstly advertising to invite Expressions Of Interest. This will allow NQPHN to identify potential providers who may be suitable to deliver the service required. NQPHN will then undertake a competitive Request for Proposal process. From here, NQPHN will execute contracts. Monitoring of performance will be conducted based on factors such as the level of risk, value, and impact of the contract. This will be assessed, and will determine the level and frequency of reporting. Specific contract managers within the organisation will be identified and meet regularly with the provider to understand any barriers, opportunities or improvements. Output indicators will include: Number of participants attending telehealth training Number of RACF staff attending triage training Number of HealthPathways uploaded for Aged Care Evaluation of all events. Outcome measures: RACF clinical staff satisfaction with the project outcomes Decrease in the number of residents for ED presentations admissions and length of stay at HHS Increase use of Aged Care HealthPathways My Health Record usage 35

36 Local Performance Indicator target Data source Proposed Activities Priority Area Activity Title / Reference Description of Activity Collaboration Increase of electronic transfer of information. Satisfaction of support Increased collaboration of RACF health care providers Reduced waiting times. Admissions and consultations of RACF residents to ED Aged Care Duration July 2016 June Coverage Commissioning approach 4.6 Aged Care - reducing avoidable admissions (New) Older Australians are high users of the health system and health expenditure in relation to avoidable admissions related to the exacerbation or acute presentation of chronic disease or preventable injury such as falls, is a high cost to the overall health system. Another significant cause of avoidable admissions is related to system failures that may occur as a lack of access to particular services, or lack of established HealthPathways or processes that result in fragmentation of the local health system. NQPHN will make available seed funding grants to support community-based aged care service providers and residential aged care facilities. This funding will be non-recurrent funding to enable these providers to put in place initiatives or enablers to address service access issues or address system fragmentation with the primary intent of reducing avoidable admissions. A broad range of stakeholders including residential aged care facilities and community aged care providers. Hospital and Health Services, emergency departments and Queensland Ambulance Service will be engaged in the development of the grants program to partner on establishing ongoing qualitative and quantitative evidence to inform grant guidelines and feedback on the impact of initiatives. The geographic coverage of these interventions and activities will be the entire NQPHN footprint. Grants program The intention of the Aged Care Grant is to provide innovative funding for all Aged Care services across the NQPHN footprint, to address priorities identified in the Health Needs Assessment that enable older people in our community to maintain dignity and 36

37 Performance Indicator Local Performance Indicator target Data source quality of life. The underlying purpose of the Aged Care Grant is to address the needs of an ageing population and the concurrent demand for services and assistance across the NQPHN footprint. The Aged Care funding Grant will be offered to all RACFS and Community Aged Care services that are not duplicating other funding sources. The target group will be older people over 65 years of age, and Aboriginal and Torres Strait Islander people over 50 years of age. Aged care is a priority for NQPHN, and through identifying current needs of this sector, gaps in service provision can be addressed. Consequently, older people in our community can enjoy significantly improved health outcomes through innovative funding grants. NQPHN will seek to understand the potential within the market by firstly advertising to invite Expressions Of Interest. This will allow NQPHN to identify potential providers who may be suitable to deliver the service required. NQPHN will then undertake a competitive Request for Proposal process. From here, NQPHN will execute contracts. Monitoring of performance will be conducted based on factors such as the level of risk, value, and impact of the contract. This will be assessed, and will determine the level and frequency of reporting. Specific contract managers within the organisation will be identified and meet regularly with the provider to understand any barriers, opportunities or improvements. Reduction in avoidable hospital admissions and presentations from facilities and community Consumer satisfaction and feedback Reduction in ambulance transfers to emergency or for acute care related to preventable conditions. Number of aged care services, general practices and other health care providers being supported by NQPHN. Contract reports from grants program Patient opinion/patient satisfaction HHS data - preventable admissions and presentations in target group Queensland Ambulance Service data. 37

38 5. Workforce The goal of NQPHN s involvement in Workforce Development is to meet the needs and build the capacity of the primary health care workforce by supporting GPs and other primary health care providers and their teams to provide the right care in the right place at the right time. The strategy acknowledges that access to ongoing education opportunities support clinicians to improve the quality of everyday clinical practice by promoting the development and maintenance of general practice skills and lifelong learning. NQPHN provides GPs, practice nurses, practice staff, dentists, pharmacists, allied health professionals and other primary health care providers with opportunities to access high-quality education and training. Education activities are designed and delivered locally based on local need, and informed by population health data to support health providers and their teams to access continued learning opportunities without the added expense of travel. In and onwards, NQPHN will: 1. Facilitate workforce development opportunities that are effective, efficient, and accessible that promote integrated systems that reduce inequity, identify gaps, and address the needs of providers, especially those that may be disadvantaged by the rurality and remoteness. 2. Build workforce capacity and skill development that better manages chronic and complex conditions providing continuity and coordinated care, targeting preventable hospital presentations and admissions 3. Facilitate leadership opportunities, with health promotion increasing the focus on preventative activities: i. Early intervention ii. Health literacy iii. Recall and reminder systems iv. Screening activities. 4. Facilitate robust workforce development planning with strong governance that is anchored in evidence and built on partnerships that provide performance accountability for ensuring quality and safety in healthcare. 38

39 Proposed Activities Priority Area Activity Title / Reference Description Workforce 5.1 Workforce Development (Continuing) Develop and deliver health workforce development strategies and strategic objectives to ensure regional, rural, and remote primary healthcare and their teams have access to appropriate opportunities for professional development, ongoing education, and skilling that facilitates improved health outcomes for consumers: Foster the value of continuous improvement across our health services Provide GPs and other health service providers with opportunities and support to participate in quality improvement activities that lead to improved health outcomes Enable all registered health service providers to fulfil their individual and vocational continual professional development requirements Meet the needs of individual education interests through the provision of high-quality accredited learning activities delivered by Royal Australian College of General Practitioners and Australian College of Rural and Remote Medicine accredited providers Deliver efficient tracking of continuing professional development points to meet Australian Health Practitioner Regulation Agency (AHPRA) requirements. Collaboration To ensure a comprehensive approach to general practice and primary care capacity building, NQPHN work collaboratively with health workforce providers including (but not limited to): Universities and TAFEs Registered Training Organisations Private hospitals and training organisations HHSs including HealthPathways teams. Duration Anticipated activity reporting period from 1 July 2016 to 30 June Coverage Commissioning approach The geographic coverage of these interventions and activities will be the entire NQPHN footprint. Workforce Development is a key priority and delivery will largely be through a direct engagement, co-design and delivery with key internal and external stakeholders, with some components of contracting to external agents for key delivery roles (expert 39

40 presenters). NQPHN will employ one Workforce Development Program Lead and two Workforce Development Program Coordinators. These positions will work collaboratively with the Indigenous Workforce Development Coordinator. Commissioning cycle: Priority review Department of Health, Health Workforce Australian Framework Needs assessment based on NQPHN s Health Needs Assessment, locally identified need, and provider surveys Design and plan Workforce Development Program Procure external services as identified Monitor and evaluate. Performance Indicator External contracted providers for workforce development are evaluated by: stakeholder feedback value for money/return of investment priority of education topic regional reach. NQPHN will directly approach the most capable provider, ensuring that all due diligence and required governance arrangements and a suitable and efficient model are in place. At the time of this approach, if there is an indication that there may be other suitable providers, then NQPHN will firstly advertise to invite Expressions of Interest. Monitoring of performance will be conducted based on factors such as the level of risk, value, and impact of the contract. This will be assessed, and will determine the level and frequency of reporting. Specific contract managers within the organisation will be identified and meet regularly with the provider to understand any barriers, opportunities or improvements. Output indicators will include: 1. Number and type of education interventions developed and delivered 2. Number and type of co-designed education interventions developed and delivered 3. Number and type of registrations for education interventions developed and delivered 4. Number and type of attendees education interventions developed and delivered. Outcome measures will include: 1. Enhanced access to clinical and non-clinical workforce capacity building interventions (number of interventions, locations, attendees, and types of delivery platform) 2. Change to clinical and non-clinical practice 40

41 3. Transition of new knowledge and skill to patient care 4. Learning expectation met 5. Relevance to daily practice. Local Performance Indicator target Data source The local performance indicator target will include: 1. Number and type of health workforce partnerships 2. Number of formal local and regional workforce partnerships groups (NQPHN Consultative) 3. Number of local and regional partnership group meetings undertaken. Data source: Event evaluations collated in the NQPHN Customer Relationship Management Database Stakeholder feedback via event evaluation Retrospective review of attendee transition of learnings into practice quarterly. 41

42 6. HealthPathways and Integration Through broad consultation, NQPHN (with healthcare providers, consumers and through clinical councils) has identified health system communication, connectivity and navigation as a critical priority. To address this, NQPHN is rolling out the My Health Record opt out trial, and HealthPathways. HealthPathways is a web-based information portal of agreed guidelines to manage specific diseases or conditions between the primary and secondary services that have been localised by a GP editor and subject matter experts, who are specialists in their professional field. A pathway includes information for assessment, management and local referral services for patient care. The HealthPathways program supports health professionals in navigating patients through the local health system and was designed in Canterbury, New Zealand. NQPHN has already invested in the development of HealthPathways, and actively participated in the successful first phase establishment and implementation of HealthPathways across the NQPHN territory with local Hospital and Health Services to support systems wide change. Additionally, NQPHN is committed to working collaboratively with local Health and Hospital Services focusing on systems improvements that support enhanced patient outcomes. In and onwards, NQPHN has developed activities and initiatives that are an extension and enhancement of HealthPathways, partnered with local HHS to co-design integrative activities and projects that will build on, strengthen, and enhance work already underway ensuring: Region-wide approaches consistency and seamless processes Consolidation of work already underway Provide sustainability and growth for a range of programs and initiatives that have been shown to affect positive system and consumer outcomes Focus on systems improvements. Proposed Activities Priority Area Activity Title Description of Activity HealthPathways, Chronic Disease, Specialist Access, My Health Record, Mental Health, Aged Care, Maternal and Child health, Aboriginal and Strait Islander Health, Substance Misuse, After Hours, Healthy Behaviours, Rural and Remote, Workforce, Mapping, Health Transport. 6.1 HealthPathways and Integration (Continuing) HealthPathways: Systems and Integration Improvement Initiative NQPHN will employ a lead and three coordinators to support the delivery and commissioning of initiatives under this activity Intensive support to the HealthPathways Programs across the NQPHN territory to further facilitate primary health care provider use of HealthPathways in practices and facilities Enhancement of already developed pathways to include allied health and telehealth 42

43 Integrate HealthPathways program to primary care provider Workforce Development Implement HealthPathways Consumer Patient Information Portal site to service the NQPHN region Facilitate an economic evaluation of HealthPathways impact and outcomes. 1. Work collaboratively with local Health and Hospital Services to implement initiatives that enhance primary and acute care integration including: ereferral Telehealth strategies Clinical Prioritisation Criteria Project Meeting General Practice Liaison Officer s KPIs Integrated education events. 2. Support the co-design and partnership delivery of activities and initiatives that: Promote intersectorial integration Improve pathways to care, in particular targeting pathways that will reduce avoidable hospital admissions and presentations, especially between primary health care and hospital services. Collaboration To ensure a comprehensive approach to the growth and innovative advancement of HealthPathways and integration activities, it is vital that NQPHN maintains high level formal and informal collaborative relationships with multiple stakeholders including (but not limited to): Health and Hospital Services (Formal: Charter Directed Partnership) Primary care providers Aboriginal and Torres Strait Islanders Medical Services (Formal: MOU) Private specialists and hospitals Residential aged care facilities. Duration Anticipated activity reporting period from 1 July 2016 to 30 June Coverage The geographic coverage of these interventions and activities will be the entire NQPHN footprint. 43

44 Commissioning approach Performance Indicator HealthPathways and integration activities are key priorities for NQPHN, with development and delivery informed by six commissioning cycle stages: Review strategic alignment Review needs assessment based on NQPHN Health Needs Assessment/locally identified need/provider surveys Plan activities Design activities Procure external services as identified Monitor and evaluate. NQPHN will directly approach the most capable provider, ensuring that all due diligence and required governance arrangements, and a suitable and efficient model, are in place. At the time of this approach, if there is an indication that there may be other suitable providers, then NQPHN will firstly advertise to invite Expressions of Interest. Monitoring of performance will be conducted based on factors such as the level of risk, value, and impact of the contract. This will be assessed, and will determine the level and frequency of reporting. Specific contract managers within the organisation will be identified and meet regularly with the provider to understand any barriers, opportunities or improvements. Output indicators will include: 70 per cent ereferrals to HHS Specialist Out Patient Department Less than 70 per cent utilising recommended care pathways 25 per cent increase in primary care provider utilisation of HealthPathways Number and type integrated education events Number and type of events where HealthPathways was showcased. Outcome measures will include: Enhanced primary and acute care connectivity Appropriate patient referral and referral pre requisites to Specialist Outpatient clients and private specialists Incorporation of Clinical Prioritisation Criteria into local care pathways Highly engaged and integrated GPLOs with NQPHN teams and primary care providers Enhanced primary care/acute care sector provider and service knowledge and understanding. 44

45 Local Performance Indicator target Data source Number and type of local HealthPathways developed as directed and funded by NQPHN Increased utilisation of telehealth technologies to increase patient access - Number and type of telehealth consultations Greater than eight attendances annually at integration-focused forums, working with each of the four HHSs in the NQPHN footprint. HealthPathways Google Analytics Data Queensland Health Clinical Prioritisation Project Outcomes data Pen Cat and Pat Cat General Practice data HHS HealthPathways NQPHN specific reports Economic evaluation report Telehealth MBS Billing data General Practice Liaison Officer reports 45

46 7. Health Promotion and Prevention The objectives of the NQPHN involvement in Health Promotion, include: Support state-wide health promotion activities and frameworks to protect the health of North Queenslanders Prevent chronic disease through early intervention strategies which promote healthy lifestyles: a. More people choosing water and healthy options b. More people physically active, engaging in walking and incidental activity c. More people tobacco and drug-free d. More people actively seeking better ways to reduce harm from alcohol, and e. Building stronger approaches to resilience and social inclusion, focusing on young people. Support health services to close the gap for Aboriginal and Torres Strait Islander people in North Queensland Work in partnership with Hospital and Health Services, government agencies, and the non-government sector to identify and foster best-practice innovations and promote good health Support initiatives that assist individuals, communities, workplaces and broader society to improve health and wellbeing. In and onwards, our organisation will: Implement innovative and locally-tailored solutions to health promotion and chronic disease prevention programs/services, based on community needs Work to address gaps in health promotion and chronic disease prevention services/programs, particularly Aboriginal and Torres Strait Islander people and people living in rural and remote communities within NQPHN s footprint. 46

47 Proposed Activities Priority Area Activity Title / Reference Description of Activity All priority areas in particularly commissioning health planning 7.1 Commissioning planning cycle and Active Healthy Northern Queensland (NQ) (Continuing) The NQPHN Health Needs Assessment identified high rates of chronic disease across the region, and high rates of predisposing behavioural risks, such as smoking, low exercise participation, low consumption of recommended fruit and vegetables, with consequential high proportion of the population of obesity and overweight leading to chronic disease (National Health and Medical Research Council 2013, Health 2014). Evidence suggests that the majority of chronic diseases can be reduced with modified health behaviours, including smoking cessation, healthy eating and increased exercise participation (Bright, Begg et al. 2009a, Bright, Begg et al. 2009b). And by commissioning the right service in the right place at the right time. To address the rising rates of chronic disease and reduce the above risk factors, the Active Healthy Northern Queensland campaign will aim to provide a whole-of-population approach to increase awareness, increase knowledge, and stimulate community action to encourage northern Queenslanders to be the healthiest people in Australia. NQPHN will achieve this by promoting health literacy and health promotion through NQPHN s Active Healthy NQ website and social media accounts, and targeted campaigns identified in NQPHN s health needs assessment at a local level. A large component of this activity is planning, codesign and collaborative action as part of our commissioning cycle. This will support NQPHN to respond to identified national and local priorities by planning for the successful purchasing/commissioning of services and programs in our footprint over the next two years. Commissioning planning As part of our six key commissioning stages (see fig. 1 below), NQPHN will plan and engage broadly with communities, clinicians, service providers, not-for-profit, voluntary sector and consumers. This will allow NQPHN to work together with all stakeholders in the development of different approaches and new, flexible and innovative service delivery methods. 47

48 Figure 1. NQPHN s commissioning cycle NQPHN s priority will be the six key priorities for targeted work: mental health, Aboriginal and Torres Strait Islander health, population health, health workforce, ehealth and aged care. And identified priorities in our health needs assessment. Within , all existing and new programs that are being commissioned or transitioned from the Department of Health to NQPHN will be continued for a further 6-12 months. During this period of time, NQPHN will plan and review each of the programs against the criteria identified in NQPHNs performance evaluation framework being developed, as well as the new service models being scoped. Following the review, NQPHN will work with the commissioned services to identify service improvements and potential collaborations/partnerships that may enhance program outcomes. A key element of the plan and design stages in NQPHN s commissioning cycle is to support a range of current providers delivering services under contract to review their services using a value-based healthcare approach to determine the cost per quality adjusted life year (if appropriate), and determine the effectiveness and efficiency of their services. The results of this planning and review will support these providers to develop skills and systems to measure and improve patient outcomes. NQPHN will support the planning and progression of the Innovation fund thereby progressing innovative approaches and solutions to improve the efficiency, effectiveness and coordination of locally-based primary health care services. This is consistent with the Australian Government s reform agenda, with a view to scaling these up within NQPHN and sharing approaches to other PHNs. 48

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