Central and Eastern Sydney PHN STRATEGIC PLAN

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1 Central and Eastern Sydney PHN STRATEGIC PLAN

2 Welcome to our plan Improving primary health care Central and Eastern Sydney PHN (CESPHN) is one of 31 primary health networks established across Australia by the Commonwealth Government to drive improvements in the delivery of primary health care. This plan covers our initial funding period to June 2018 and will be reviewed in line with ongoing funding cycles. Primary health care may be viewed as the first point of contact an individual has with the health system. In recent years however it has evolved to be the hub and home of good health care offering integrated and coordinated care by a range of health care professionals including GPs, nurses, psychologists, pharmacists, dentists, physiotherapists, Aboriginal health workers and many more. Primary health care services address not only the immediate problem, but also include prevention, screening, chronic disease management and health promotion. Primary health networks are responsible for improving the health of the local population through coordinating the planning, designing and delivery of effective, equitable and evidence-informed primary health care. We achieve this by collaborating with our local hospitals, health services and other key partners to: develop local strategies to improve and better coordinate integrated care across the health system reduce avoidable hospital presentations and admissions ensure people receive the right health care in the right place at the right time. CESPHN was established on 1 July 2015 as a company limited by guarantee, with an inclusive governance structure representing allied health, community and general practice. Our member networks are: Sydney Health Community Network Central and Eastern Sydney Allied Health Network Central Sydney GP Network GP Crew Limited St George Division of General Practice General Practice Eastern Sydney Sutherland Division of General Practice Strengthening this governance structure are our Community Council and Clinical Council who provide strategic insight and expertise on community and clinical issues. Both councils assist in identifying opportunities to improve health services and where there may be gaps in services. They also provide strategic advice about population health planning and commissioning of services. Our Clinical Council is GP led and comprises other health professionals who have the knowledge and skill set to advise on pathways of integrated and coordinated care. Our Community Council ensures that our investments and innovations are person-centred, locally relevant and aligned to local care experiences. 1

3 About us Strategic foundations Our values Our vision Accountability Collaboration Courage Innovation Integrity Passion Perseverance Quality Teamwork Values Vision Supporting, strengthening and shaping a world class, person centred primary health care system. Behaviours Purpose Cultural success factors A clear focus True partner Fostering innovation A great place to work Our Purpose To improve primary health care, facilitate seamless care and address local health needs for the people who live in, work in and/or visit central and eastern Sydney, Lord Howe Island and Norfolk Island by working in partnership with our GPs, allied health professionals, nurses, local health districts, specialty health networks, our local communities, nongovernment organisations and our other health professionals and services. 2

4 Strategic goals What we need to do 01 Improve health outcomes and address health needs 03 Work in partnership to facilitate seamless person centred care 02 Support our primary health care professionals and services 3

5 01 Improve health outcomes and address health needs What this goal is about... This goal is about working in partnership to improve the health of communities within our region, improve health outcomes for patients and clients of our primary health care services and to provide targeted, person-centred primary health care services to those in most need. Achieving this goal requires an informed evidence base on the demography, diversity, health status, health needs and priorities of communities within our region. It requires strong partnerships with our local health districts, specialty health networks and community organisations as well as effective engagement with health consumers and carers. It requires application of proven interventions, adoption of innovative models of care and a continuing translational research agenda to put evidence into practice. Where services are deficient, commissioned models of care will be employed to drive local service improvements. It will need general practices and their allied health colleagues to focus on the health of the communities they serve, as well as providing quality primary health care to individuals. It requires working with other players outside of the health sector to build an environment to support principles of health literacy, healthy choices and behaviours and reduce avoidable risks to health. Strategies to achieve this... Commission effective, responsive and integrated health care services in the areas of mental health, suicide prevention, drug and alcohol, Aboriginal health, after hours and other locally relevant areas of need Develop innovative drug and alcohol service models that are appropriate for our diverse community Develop innovative solutions to better support those people with chronic and complex health conditions to keep them well in the community Develop joint action plans to strengthen primary health care access and services for priority populations Establish an integrated stepped care mental health model to improve timely access to care to optimise recovery and support better self-management Guided by the Clinical and Community Councils, work with the local health districts and specialty health networks to identify the major health priorities where primary health care can make a real difference to health outcomes, and develop joint, evidence based action plans In partnership with local health districts and specialty health networks update the health needs analyses undertaken in 2016 and prepare a joint PHN health atlas outlining the demography, diversity, health status and health needs of communities within the region Localise the PHN health atlas to geographical regions to provide primary health care practices with information on the health status and health needs of our local communities Support the provision of health literate environments and provide communities with tools to improve the health literacy of individuals 4

6 02 Support our primary health care professionals and services What this goal is about... This goal is about ensuring that we effectively support our GPs, allied health professionals, nurses and other health professionals working in primary health care to provide high quality, evidence based, person-centred health care. Informed and guided by our Clinical and Community Councils, this support will include practice support, continuing professional development, accreditation support, digital health connectivity, information on local health and service needs, provision of and access to programs, services, information, tools and resources. We will continue to actively support and engage our member companies and Councils in planning and strategic processes. We will be an advocate for primary health care and an active player with the local health districts, specialty health networks and local government to ensure inclusion of primary health care needs in growth centres and urban planning. In partnership with the Clinical and Community Councils, we will develop a primary health care sustainability plan to address service gaps and longer term workforce planning issues. We need to facilitate linking primary health care professionals and practices with national and international best practice and national models of care to inform and support quality care and practice systems. We will maintain dedicated support to our general practitioners and allied health professionals across our region, including those on Lord Howe Island and Norfolk Island. Strategies to achieve this... Assist GPs to assess and document the health status of their patients and to initiate evidence based strategies to address health risk factors and behaviours Build the capacity of our local workforce to better manage drug and alcohol problems Identify and link with appropriate primary health care improvement think tanks and research groups to facilitate shared learning and benchmarking In partnership with our Councils assist GPs to meet evidence based health outcome indicators In partnership with our Councils, local health districts and specialty networks, undertake primary health care workforce planning in In partnership with the local health districts and specialty health networks, develop an agreed roll out of HealthPathways across the PHN region Provide an effective digital health platform including My Health Record to facilitate adoption and meaningful use of digital health functionality by primary health care practices Support delivery of evidence based professional development opportunities for health care professionals involved in the provision of primary care Support key CESPHN engagement mechanisms including the Clinical Council and Community Council, and our seven CESPHN member networks Support our general practices to achieve and maintain accreditation Particularly in mental health, lead regional workforce development to enable professionals from different settings to collaborate and learn together Work with local health districts, specialty health networks and local government to ensure primary health care needs are included in planning for new urban developments in our region Work with primary care to enable better and more flexible care coordination and delivery of care for complex and chronic conditions across the elements of the health care home model 5

7 03 Work in partnership to facilitate seamless person centred care What this goal is about... This goal is about working with our key partners to support and facilitate access to the right care, in the right place and at the right time, across the six tiers of health care self-care, primary care, community based care, coordinated care, secondary care and tertiary care. It is about working with our key partners to develop and implement the foundation for health care homes to appropriately transform the coordination and delivery of person-centred services, particularly for people living with a long term chronic condition, people with special needs and people at risk of poor health outcomes. Where key gaps are identified, we will work to address these. Where appropriate, we will partner with the community and service providers to co-design solutions, built around the needs of health consumers, their families and carers. This goal seeks to embed proven concepts of integrated care, the person-centred medical home, shared digital health records, preventive care, carer support, health literacy and self-care across primary health care in the PHN. Strategies to achieve this... Enhance and expand GP and allied health coordinated care programs with hospitals and private specialist services for people living with a chronic mental illness, people being treated for cancer, pregnant women, transition points of care and people with a terminal illness In partnership with our Clinical and Community Councils, local health districts, specialty health networks and other partners, develop joint action plans to address service gaps and problems with service access Provide opportunities to community groups and service providers to be partners in the co-design of solutions for commissioned services Support people navigating the health system by establishing links to existing consumer and carer portals, e.g. My Aged Care, NDIS and healthdirect Develop a regional approach to planning, commissioning and performance monitoring through the primary mental health care reforms With the support of our Community Council, work with key partners to support health consumers to become active partners in their health care Work in partnership with local health districts, specialty health networks, non-government organisations and private organisations to establish effective drug treatment systems through a flexible menu of treatments which address the diversity of drug problems, provided by a range of different service providers working collaboratively Work in partnership with our local health districts and specialty networks to support effective local implementation of the NSW Health Integrated Care Strategy, and where possible jointly commission activities to improve service efficiencies Work with key partners to establish an innovative and effective model of localised primary health care through setting the foundations of health care homes to enable more effective coordination and delivery of care across the six tiers of health care 6

8 Priorities and objectives PRIORITIES AND OBJECTIVES OF PRIMARY HEALTH NETWORKS PHN objectives Increase the efficiency and effectiveness of health services for individuals, particularly those people at risk of poor health outcomes Improve coordination of care to ensure people receive the right care in the right place at the right time. PHN Priorities Reduce avoidable hospitalisations and emergency department presentations Improve health outcomes for people with complex chronic conditions. Aboriginal health Aged care Digital health National health priorities Health workforce Mental health Population health Funding priorities including commissioning activities After Hours Innovation Mental Health and Suicide Prevention Alcohol and Other Drugs Treatment Partners in Recovery Integrated Team Care (Aboriginal Health) Norfolk Island IDENTIFIED LOCAL PRIORITIES AND GOALS Strategic goals Improve health outcomes and address health needs Support our primary health care professionals and services Work in partnership to facilitate person centred seamless care Aboriginal and Torres Strait Islander Health Addressing service gaps Aged care Alcohol and other drugs Areas with poor health status Care coordination Child and maternal health Digital health Local priorities identified through needs assessment Early intervention and prevention Health literacy Integrated care Mental health Population health Service navigation Workforce HOW WILL SUCCESS BE MEASURED? National headline indicators Potentially preventable hospitalisations Childhood immunisation rates Cancer screening rates (cervical, breast, bowel) Mental health treatment rates (including for children and adolescents) Organisational indicators Governance Financial management Stakeholder management Delivery of contracted services and any direct services 7

9 Our region and population The central and eastern Sydney catchment spans square kilometres, stretching from Strathfield to Sutherland, as far east as Bondi, and also includes Lord Howe Island and Norfolk Island. We are the second largest PHN across Australia by population, with almost 1.5 million individuals residing in our region. Our boundaries align with those of South Eastern Sydney Local Health District and Sydney Local Health District. Our catchment population is characterised by cultural diversity and high population growth with more than a third (35%) of our community born outside Australia. By 2031 our region s population will reach more than 1.85 million, an increase of 28.1%. We work with our diverse communities and priority populations including, Aboriginal people; people from culturally and linguistically diverse communities; refugees; people who are homeless; people living with complex mental illness; people with alcohol and other drug use disorder; people at risk of HIV/AIDS; lesbian, gay, bisexual, transgender, intersex, questioning (LGBTIQ); ageing population; children and young people and people with disability, to keep them well and out of hospital. We will continue to engage with our community by: offering forums and workshops whereby all health consumers and their carers can contribute to identifying health needs and where services need to improve providing opportunities for the community to participate in the co-design of locally focused and relevant health services ensuring health literacy principles are embedded across our programs to improve the community s knowledge in finding, understanding and using information about their health and health care. Our Board of Directors, Community and Clinical Councils, primary health care professionals, local health districts, specialty health networks, universities and other non-government organisations have shaped this plan. The priority areas identified in this plan have been informed by our baseline needs assessment which was undertaken in partnership with our local health districts and specialty health networks. Our priorities align with national and local health priorities, as well as primary health network specific priorities and key performance areas as determined by the Commonwealth Department of Health. Our strategic plan outlines our direction to reform primary health care service delivery and our contribution to improve targeted health service provision over the next two years. We will achieve this by: working towards a person-centred health care system by setting the foundations for the Health Care Home model developing high quality, locally-responsive solutions that are cost effective and co-designed by the communities they serve identifying and addressing inefficiencies in our health system and building the health workforce to support this fostering innovation through better coordination and integration of local services to meet the needs of people and their communities. 8

10 A local approach Addressing our communities needs We will engage with our local communities to co-design appropriate services, ensuring lived experience, consumer and carer representation throughout this process. We will work with providers to commission locally integrated services to improve cost and resource efficiency across our catchment with the ultimate aim of improving equitable access to health care for the people of central and eastern Sydney and a better patient experience. Foundation of Health Care Homes As part of the reform of primary healthcare system, the Government has introduced the concept of Health Care Homes. A Health Care Home is a home base where patients with chronic and complex conditions can receive improved access to coordinated and wrap around support for their health care needs. General practices and Aboriginal Medical Services can serve as Health Care Homes. Key elements of this approach are: people nominate their preferred practice or health care provider for coordination, management and ongoing support for their care consumers, families and their carers are empowered to be partners in their care individuals have greater flexibility in access to care provided by their preferred practice or health care provider integrated care is supported through flexible service delivery options that are safe and of high quality including the implementation of quality improvement models. Funding priorities Mental health and suicide prevention, and alcohol and other drug treatment are our largest funding priorities for the next two years. We are working in partnership with our local health districts, specialty health networks, the NGO sector, general practice, allied health, private health organisations, communities, consumers and carers to ensure health services are delivered efficiently and effectively, in a way that best meets the needs of our diverse communities. Primary mental health and suicide prevention services are undergoing significant reform. Our priority is to design and establish an integrated stepped model of care for people with any level of mental health need. Alcohol and other drug treatment is a relatively new arena for primary health care to play a lead role in. We will be developing and delivering a flexible range of treatment services, to drive better health outcomes for people living with alcohol and other drug use disorder problems. Commissioning In July 2016 CESPHN implemented a commissioning model to deliver new models of care. Commissioning is a strategic approach to procurement, informed by our needs assessment and market analysis. Commissioning supports a comprehensive approach for us to plan and contract medical and health care services to meet our identified population health needs, improve efficiencies in the health system, and address health inequalities whilst keeping the patient at the centre of their care. Innovation Innovative approaches and solutions are fostered through encouraging creativity, sharing of ideas and supporting an environment to remove barriers and adopt better practice. The Commonwealth Department of Health has provided us with innovation funding to implement activities that improve the efficiency, effectiveness and coordination of locally based primary health care services. 9

11 Our PHN at a glance Last updated August 2016 CURRENT POPULATION TOTAL POPULATION 1,497, % 50.2 % LIFE EXPECTANCY ABORIGINAL BORN OUTSIDE AUSTRALIA SPEAK LANGUAGE OTHER THAN ENGLISH AT HOME PHN 0.8% NSW 2.5% HEALTH & LIFESTYLE INFORMATION Overweight or obese Identify as smokers Physically inactive Consume alcohol at risky levels High/Very High levels of Psychological Distress Household owns a car PROJECTED CHANGE IN POPULATION YEARS YEARS 65+ YEARS AREA PROFILE PHN 35% NSW 26% PHN NSW 4.8 1, [%] PHN 35.2% NSW 22% Hospital admissions PER DAY 1,932 Avoidable hospital admissions PER YEAR 15.7% 0-14 YEARS 16.3% 2031 TOTAL 70.9% YEARS 66.9% 65+ YEARS 13.4% 16.8% 87% Rate their health POSITIVELY 84% Saw a GP in the PAST YEAR per 100,000 population POPULATION 1,851, Public Hospitals Local Health 2 Districts 2 Hospital Networks 667KM² 5 headspace Sites Aboriginal Medical Service 1 Land Area ^2,400 General Practitioners ^4,500 ^480 Allied Health Professionals Practice Nurses 10

12 Kogarah Office Level 3, 15 Kensington St Kogarah NSW 2217 T F Ashfield Office Level 1, 158 Liverpool Rd Ashfield NSW 2131 T F /cesphn company/central-and-eastern-sydney-phn