Updated Activity Work Plan : Core Funding After Hours Funding

Transcription

1 Updated Activity Work Plan : Core Funding After Hours Funding The Activity Work Plan template has the following parts: 1. The updated Core Funding Annual Plan which will provide: a) The updated strategic vision of each PHN. b) An updated description of planned activities funded by the flexible funding stream under the Schedule Primary Health Networks Core Funding. c) An updated description of planned activities funded by the operational funding stream under the Schedule Primary Health Networks Core Funding. d) A description of planned activities which are no longer planned for implementation under the Schedule Primary Health Networks Core Funding. 2. The indicative Core Operational and Flexible Funding Streams Budget for (attach an excel spreadsheet using template provided). 3. The updated After Hours Primary Care Funding Annual Plan which will provide: a) The updated strategic vision of each PHN for achieving the After Hours key objectives. b) An updated description of planned activities funded under the Schedule Primary Health Networks After Hours Primary Care Funding. c) A description of planned activities which no longer planned for implementation under the Schedule Primary Health Networks After Hours Primary Care Funding. Central and Eastern Sydney PHN When submitting this Updated Activity Work Plan to the Department of Health, the PHN must ensure that all internal clearances have been obtained and that it has been endorsed by the CEO. The Activity Work Plan must be lodged to <name of Grant Officer> via < address> on or before 17 February

2 Overview This Activity Work Plan is an update to the Activity Work Plan submitted to the Department in May (a) Strategic Vision Central and Eastern Sydney PHN (CESPHN) Strategic Vision Our strategic vision is to support, strengthen and shape a world class, person centred primary health care system. We do this by working in partnership with GPs, allied health professionals, nurses, local communities, non government organisations, local health districts and speciality health networks. CESPHN is governed by a skills based board that reports to seven member organisations representing general practice, allied health and community. The Board is advised by a Clinical Council and Community Council. All these groups have been actively engaged in the needs assessment process and the identification of priorities for activity in Our region has a growing and diverse population. Not all people have equal access to health services and as a PHN we are committed to improving health literacy and assisting the most socioeconomically disadvantaged populations to access services. Many of our activities are therefore targeted to high need areas or groups. We are committed to building consumer capacity for self management and to make informed choices. Our aim is to understand and improve workforce capacity, capability and retention. We play a key role in the provision of workforce support to primary health care providers to encourage quality improvement and skill development. We do this through the provision of education programs and individualised practice support. We will continue to build our understanding of the CESPHN area and support the collection, interpretation and sharing of population health data between the PHN, LHDs and key stakeholders. As an organisation, we are committed to fostering learning approaches including working closely with other PHNs and universities. We will use robust evaluation techniques to assess success. From July 2016 CESPHN has been moving to implement a commissioning model with responsibility for using funds to procure the provision of services from external providers. We will develop quality primary health care services and associated interventions that deliver better health outcomes, meet population health needs and reduce inequalities within the resources available. In doing this we are committed to working collaboratively with service users and service providers to co-design appropriate models of care. 2

3 EXECUTIVE SUMMARY This activity plan has been developed using information from our comprehensive needs assessment submitted in November 2016 and further shaped through feedback sought from key stakeholders on priority health and service needs, data, opportunities and options to address priority areas. Key outcomes from the stakeholder strategic planning day held in January 2017 provided the opportunity to further refine and develop activities. The development of the Activity Work Plan responds to the needs of the community through the identification of new needs and areas for greater focus, these included youth health, veterans, homelessness, CALD and refugees, disability and rural health. Alongside this, CESPHN continues to move towards a commissioning model, key services to be commissioned in include: HealthPathways for both Sydney and South Eastern Sydney regions Rockdale Women s Health Service Falls Prevention programs for elderly people with mild to moderate cognitive impairment Bilingual Community Educator model Lifestyle modification program in areas of high need Paediatric speech therapy services for children with developmental delay in areas of disadvantage Disability education programs The plan identifies activities against sixteen priority areas to be delivered over the course of These include: 1. Chronic Disease Prevention and Management 2. Sexual Health 3. Ageing 4. Immunisation 5. Disability 6. Service navigation and pathways 7. Maternal Health 8. Child Health / Youth Health 9. Emerging needs / Priority Populations (Veterans; people experiencing homelessness or at risk of homelessness; Domestic and family violence 10. Culturally and Linguistically Diverse people and Refugees 11. Rural Health (Lord Howe Island and Norfolk Island) 12. Workforce 13. Digital Health 14. Aboriginal and Torres Strait Islander Health 15. Mental Health 16. Alcohol and Other Drugs The priority areas of Rural Health, Digital Health and Workforce are addressed through the operational funding streams. The priority areas of Aboriginal and Torres Strait Islander Health, Mental Health and Alcohol and Other Drugs Treatment are covered in separate activity work plans. 3

4 The activity plan also outlines four key activities funded through our operational funding stream. These are: Primary Care Workforce Support (OP1) Digital Health (OP2) Planning, Strategy and Evaluation (OP3) Stakeholder Management and Engagement (OP4) 4

5 Core Flexible Funding Priority Area Activity Title 1 Population Health NP 1.1 Quality Improvement and Chronic Disease Management NP 1.2 Cancer Screening and Prevention NP 1.3 Chronic Disease Prevention NP 1.4 Sexual Health coordinated approach to primary care, education, and prevention for STIs and BBVs NP 3.1 Immunisation NP 6.1 Maternal Health NP 7.1 Child and Youth Health NP 9 Emerging needs NP 10 CALD and refugees 2 Aged Care NP 2.1 Aged Care - Sector Support through Education, Networking and Upskilling the aged care workforce. 4 Health Literacy NP 4.1 Can Get Health in Canterbury NP 4.2 NDIS Readiness 5 Service Navigation and Pathways NP 5.1 HealthPathways Sydney Program NP 5.2 South Eastern Sydney HealthPathways Program 8 Workforce NP 8.1 Continuing Professional Development (CPD) inclusive of Small Group Learning Program (SGL) 5

6 Core Operational Funding OP1 - Primary care workforce support accreditation, practice management and workforce support OP 2 - Digital Health OP 3 - Planning, Strategy and Evaluation OP 4 Stakeholder Management and Engagement After Hours Primary Health Care Reducing inappropriate ED presentations for targeted communities 2.1 RACF Service Improvement Projects 3.1 After Hours service promotion 4.1 Lord Howe and Norfolk Island Telehealth Initiative 4.2 MyHealth Record 5.1 Uptake of After Hours PIP 6.1 Transition of St George After Hours GP Clinic Service provision to new provider 7.1 After Hours Mental Health Support Line 6

7 1. (b) Planned PHN activities Core Flexible Funding Proposed Activities Activity Title / Reference (eg. NP 1) Existing, Modified, or New Activity Program Key Priority Area Needs Assessment Priority Area (eg. 1, 2, 3) NP 1.1 Health System Redesign and Quality Improvement NP 1.1 Quality Improvement and Chronic Disease Management Modified (combination of NP 1.1, NP 1.4 and NP7.1 from plan) Population Health Chronic disease prevention and management pg Section 4 Diabetes- Possible Options p.54 Engage primary care in continuous QI projects such as Pitting Data into Practice Explore options around better use of MBS items regarding chronic disease management Support LHDs in the delivery and improvement of community based diabetes education Promote use of National Diabetes Services Scheme for patients diagnosed with diabetes Respiratory (Asthma and COPD) Possible Options p. 54 Support GPs to better manage respiratory illness through evidence based intervention in partnership with research institutions and other providers (explore commissioning) Improve GP management of Asthma in children to reduce avoidable hospital presentations (explore commissioning) Explore options around better uses of MBS items regarding chronic disease management. Description of Activity NP1.1 Health System Redesign and Quality Improvement 7

8 Support the development, implementation and evaluation of a range of integrated care strategies in consultation with key stakeholders, such as local health districts and networks, with a focus on: Identification of individuals at high risk of hospitalisation and early referral to appropriate interventions (Risk Stratification and resource matching tools), Care pathway and coordination of care between LHDs, GPs, and clients (shared care planning and information sharing), Establish GP clusters to identify gaps and opportunities for service improvement e.g. Breakthrough Collaborative/ geographic clusters, Identification of local primary care clinical leaders to drive change across the region. Engage primary care in collaborative continuous quality improvement (QI) activities: Work in partnership with GPs, PNs and practice managers, Local Health Districts and private health professionals to improve the quality of care and service delivery for people with chronic diseases, Build primary care capacity to embed effective evidence-based improvement tools in their practice through the delivery of a range of QI projects. NP 1.4 Chronic Disease management Long term conditions and hospital avoidance. Addressing the burden of an aging population and increasing prevalence of chronic disease within target populations by developing and implementing a range of clinical redesign projects and evidence based best practice interventions. Activities include: Develop and enhance access to care pathways to cost efficient and effective community based activities for people with long term conditions such as diabetes, COPD and heart disease; Partner with key stakeholders to plan, deliver and evaluate projects that aim to enhance early identification and intervention for people with or at high risk of developing chronic disease such as young onset type 2 diabetes, uncomplicated diabetes and CVD; Work in partnerships with LHDs to identify and target populations at high risk of emergency presentation and/ or hospital admission; 8

9 Enhancing primary care uptake of initiatives and projects designed to improve management of patients with long term conditions such as Annual Cycles of care for asthma and diabetes, care plans; Foster a culture of interdisciplinary care and collaboration, eg supporting the establishment of nurse led clinics, appropriate referral to AHP in private sector; Determine the role of the PHN in moving to health home model of care and bundled primary health care payment system for patients with chronic disease (2017 onwards). NP7.1 Addressing Service Gaps Community diabetes education programs for people with low risk/uncomplicated diabetes AIM Improve chronic disease prevention, identification, and management through capacity building within primary care focusing on diabetes, respiratory disease, cancer screening ACTIVITIES 1. Deliver projects in partnership with GPs, PNs and practice managers, Local Health District s and private health professionals to people with/at risk of developing chronic diseases 2. Provide education (e.g.: CPD) to primary care providers on prevention and management of people with diabetes, respiratory and cancer 3. Monitor and evaluate commissioned community based diabetes education programs in SLHD region for people at risk or newly diagnosed type 2 diabetes (with a focus on high prevalence and low socioeconomic areas) 4. Promote existing ComDiab sessions in the SESLHD region 5. In partnership with SESLHD plan and deliver specific ComDiab programs for hard to reach communities (including CALD groups) 6. Deliver QI projects to general practices focusing on diabetes, cardiovascular diseases, respiratory disease and cancer screening 7. Identify and address priority areas/populations with general practices who are participating in QI projects 9

10 8. Undertake general health promotion activities (e.g.: promotion of NDSS or other localised services) EXPECTED OUTCOMES 1. At least 4 projects/initiatives delivered in partnership with GPs, PNs and practice managers, Local Health Districts and other key stakeholders targeting people with/at risk of developing the target chronic diseases 2. At least 3 CPD activities delivered to primary care providers 3. At least 1 commissioned activity delivered in line with funding agreement and achieving KPIs 4. Maintain attendance at ComDiab sessions in the SESLHD region 5. Deliver at least 1 specific ComDiab program for hard to reach communities (including CALD groups) 6. At least 2 QI projects delivered to general practices focusing on diabetes, cardiovascular diseases, respiratory disease and/or cancer screening 7. At least 30 general practices will be supported in QI projects to identify and address priority areas Target population cohort Consultation Collaboration Indigenous Specific Duration GPs, practice nurses, practice staff and AHPs in the region Patients with or at risk of developing type 2 diabetes, respiratory diseases and cardiovascular diseases Diabetes NSW & ACT LHDs Sydney Local Health District and South Eastern Sydney Local Health District - collaboration around projects, care pathways, service integration and new models of care. Diabetes NSW, Heart Foundation, Asthma Foundation NO Q1 10

11 1 activity commissioned QI Category 1 CPD activity available Q3-4 Implementation of new initiative and continue with QPulse and Breakthrough Q4 Finalised evaluation of commissioned activities and planning for new commission cycle Coverage Approach to market Decommissioning Whole PHN region, with a focus on areas of particularly high prevalence, that will include populations with highest diabetes burden and risk. N/A N/A 11

12 Proposed Activities Activity Title / Reference (eg. NP 1) Existing, Modified, or New Activity Program Key Priority Area Needs Assessment Priority Area (eg. 1, 2, 3) NP 1.2 Cancer Control renamed to NP 1.2 Cancer Screening and Prevention Modified (Combination of NP 1.2 and NP 1.3 from plan) Population Health Population Health Chronic Disease Prevention and Management Section 4: Possible Options Cancer (p55) Work with GPs in identified areas of low participation to improve participation rates in cancer screening programs through the Cancer Institute Grant, Quality Systems and Local Leaders improving primary care systems and knowledge across the three screening programs Improve access to cervical screening services for identified areas of need, such as the Rockdale Women s Health Service (commissioned service). Build primary care capacity to improve uptake of cancer screening programs. Work with peak cancer organisations to improve data sharing Scope evidence based intervention addressing identification and management of prostate cancer Maintain partnerships with Cancer Institute to ensure there is a primary healthcare focus. Description of Activity NP 1.2 Cancer Control 1. Increase participation rates in the cervical, breast and bowel cancer screening programs, with a particular focus on priority population groups and areas of low participation. 12

13 2. CESPHN will work to build primary care capacity by: Working with general practices to implement quality improvement initiatives to improve practices ability to systematically increase screening participation within their practice population, including increasing the usage of HealthLink to obtain cervical screening overdue lists and implement reminder/recall systems from the Pap test register; Promote screening programs, resources and services (including the women's health service) through PHN communication channels; Preparing for changes to the cervical cancer screening test and cervical and bowel cancer screening frequency. 3. CESPHN will be involved in service development/liaison activities, including: Work with key stakeholders to develop targeted interventions aimed at specific population groups and/or geographic regions with low screening rates and prepare for imminent changes to cervical and bowel cancer screening programs such as working with LHDs to manage capacity to provide access to timely colonoscopy in line with more frequent screening intervals and increasing BreastScreen NSW participation rates; Partner with SESLHD to deliver the MultiLevel Innovators Project to upskill GPs in skin cancer detection and treatment (to June 2017 only). NP 1.3 Women s Health Clinic The Rockdale Women s Health Clinic provides women s health checks including cervical screening for women referred by GPs in the Rockdale and Kogarah LGAs. The service aims to provide: cervical cancer screening for target age women in the Rockdale and Kogarah LGAs who are of a CALD background and/or are unscreened or underscreened. A local referral pathway for GPs who choose not to offer cervical screening, or whose patients prefer to be screened elsewhere. It is the only local, no-cost cervical screening provider in the community outside of the general practice setting 13

14 Rockdale and Kogarah LGAs have amongst the lowest cervical screening rates within the PHN. Rockdale below the CESPHN and NSW screening rate and is the 3 rd lowest in the region. In these two LGAs, the percentage of population born overseas, and percentage born in non-english speaking countries is higher than PHN and NSW average. Main countries of birth other than Australia are China, Greece, Lebanon and India. For some of these women it is not culturally appropriate for a male to perform a pap smear. The general practice workforce in the target LGAs is dominated by male GPs. Accordingly, there is a greater ratio of women in the target age range to male GPs in these areas than the CESPHN average. A review of the current service model has found that whilst it is well utilised and clearly fills a need, the model is not as cost effective as other potential models such as nurse outreach. In order for CESPHN to continue to meet the needs of the local community, the PHN intends to commission this service. The service would continue to be delivered in its current format for six months with a view to transition to a new more cost efficient and effective service model commencing 1st January AIM Increase participation rates in the cervical, breast and bowel cancer screening programs through primary care, with a particular focus on priority population groups and areas of low participation. ACTIVITIES 1. Continue working in partnership with Cancer Institute NSW, SESLHD, University of NSW and SLHD to deliver the Cancer Institute NSW Screening and Prevention Grant Project 2. Monitor and evaluate commissioned activity: Rockdale Women s Health Service including scoping the potential to expand the general practice outreach model to other regions within the PHN subject to evaluation of the service. 14

15 3. Support primary care with upcoming changes to the national cervical and bowel cancer screening programs 4. Deliver education (e.g.cpd) to primary care provider on cancer screening programs 5. Scope evidence based interventions addressing identification and management of prostate cancer 6. Continue leadership of South Eastern Sydney Women s cancer working group EXPECTED OUTCOMES 1. Cancer Institute NSW Screening and Prevention Grant Project delivered in line with funding agreement. 2. Increase general practices (15 practices) capacity to systematically address cancer screening 3. Commissioned activity: Rockdale Women s Health Service deliver in line with funding agreement and achieving KPIs 4. Determined strategies with general practices to implement the renewal cervical screening program 5. At least 3 CDP activities will be delivered to primary care providers on cancer and cancer screening programs 6. Identified evidence based interventions for early diagnosis and management of prostate cancer Target population cohort Consultation Collaboration General Practices Consumers eligible to participate in the national cancer screening programs: Cervical Screening: women years Breast screening: women years Bowel screening: men and women over 50 years Family Planning NSW regarding Rockdale Women s Health Service Cancer Institute NSW SESLHD research hub CINSW: Grant funders and provision of cancer screening rates. Ongoing collaboration re implementation of screening programs and a primary care level. 15

16 Indigenous Specific Duration Coverage Approach to market Decommissioning Family Planning NSW: Commissioned to deliver Rockdale Women s Health Service collaborative work to implement, support and promote the service. SLHD and SESLHD: Collaboration on CINSW grant project and work to improve access to diagnostic services. BreastScreen: Work to promote screening NO Q2 - Cancer Screening CPD activity delivered Q3 - Established strategies to implement the renewal cervical screening program in general practices Q4 - Finalised evaluation on commissioned activity: Rockdale Women s Health Service Completed scoping documents on evidence based interventions for early diagnosis and management of prostate cancer Rockdale Women s Health Service: Rockdale and Kogarah regions (former LGAs) CINSW grant project: Former LGAs of Rockdale, Botany Bay, Sydney, Canterbury, Strathfield Other work covers the entire PHN region, with a priority given to areas of particularly low screening participation N/A N/A 16

17 Proposed Activities Activity Title / Reference (eg. NP 1) Existing, Modified, or New Activity Program Key Priority Area Needs Assessment Priority Area (eg. 1, 2, 3) NP3.1 Preventative Health Renamed to NP 1.3 Chronic Disease Prevention Modified (combination of NP 3.1 and NP 7.1 from plan) Early Intervention Population Health Chronic disease prevention and management Healthy Lifestyle (pg.52) Section 4 Support the establishment of no/low cost Lifestyle Modification Programs in areas of highest need (including for Aboriginal populations) Raise awareness of the Get Healthy Coaching Services NP 3.1 Preventative Health Description of Activity Preventing the onset of chronic disease and enhancing quality of life by addressing the increasing incidence of overweight and obesity and supporting greater adoption of healthy lifestyle across the region. 1. Increase access and referrals to locally available prevention programs through engagement with and raising awareness amongst primary care providers and consumers including the Get Healthy Coaching Services; 2. Facilitate the establishment of local preventative health activities in collaboration with LGA and private health insurers, particularly focussing on areas with limited service options; Botany Bay, Marrickville, Rockdale, and Canterbury LGAs. Preventing the onset of chronic disease and 17

18 enhancing quality of life by addressing the increasing incidence of overweight and obesity and supporting greater adoption of healthy lifestyle across the region. 3. Increase access and referrals to locally available prevention programs through engagement with and raising awareness amongst primary care providers and consumers including the Get Healthy Coaching Services; 4. Facilitate the establishment of local preventative health activities in collaboration with LGA and private health insurers, particularly focussing on areas with limited service options; Botany Bay, Marrickville, Rockdale, and Canterbury LGAs. NP 7.1 Addressing service gaps Community based lifestyle intervention programs for people with and at risk of developing chronic diseases Affordable allied health and specialist services for people who are overweight or obese without complications AIM Minimise the risk factors that contribute to the onset of chronic disease and reduction of quality of life. ACTIVITIES 1. Promote local services which support healthy lifestyle choices to primary health care, such as the Get Healthy Coaching Service AIM Improve access to localised lifestyle modification programs in identified areas of need. ACTIVITIES 1. Monitor and evaluate commissioned activity: HEAL program in Canterbury LGA 2. Scope to expand the commission model to other areas of need 18

19 EXPECTED OUTCOMES 1. HEAL program in Canterbury LGA delivered in line with funding agreement and KPIs 2. Evaluation report on the program effectiveness of the HEAL program in Canterbury LGA 3. Delivery of a minimum of 12 HEAL programs in Canterbury LGA 4. Increased physical activity levels after program completion Target population cohort Consultation Collaboration Indigenous Specific Duration Coverage Approach to market Decommissioning Consumers in the target areas of Botany Bay, Marrickville, Rockdale and Canterbury (former LGAs) Private AHPs Local councils Lifestyle modification program providers LHDs Local councils Private allied health professionals NGOs NO Q1 - Commence health promotion on Get Healthy Service to primary health care Q4 - Finalised evaluation on commissioned HEAL program LMPs will cover target LGAs Healthy lifestyle service promotion will cover all regions, with a focus on target LGAs Open tender N/A 19

20 Proposed Activities Activity Title / Reference (eg. NP 1) Existing, Modified, or New Activity Program Key Priority Area Needs Assessment Priority Area (eg. 1, 2, 3) NP1.5 Sexual Health coordinated approach to primary care, education, and prevention for STIs and BBVs NP 1.4 Sexual Health coordinated approach to primary care, education, and prevention for STIs and BBVs Modified activity (NP 1.5 from plan plus new activities including liver check day ; nurse led model of care; PRISM test of change; priority populations) Population Health Sexual Health Section 4 p.63) Workforce development and education increase role of practice nurses around STI testing and need for early treatment, management and follow up. Improve GP capability for opportunistic testing for STIs in priority populations Increase number of GP prescribers for HVB, HVC, HIV S100 medications Explore increasing role of primary care in offering HCV management and follow up among people from priority populations. Education Education for health professionals including for new treatments. Hepatitis C Integration Trialling a shared care model for HIV with Albion Centre and general practice Focused work with LGBTIQ CALD and Aboriginal populations ichat 20

21 Review outcomes of the I-Chat Initiative (Hepatitis Nurses working with primary care across the region) for future applications NP1.5 Sexual Health 1. Provide and promote CPD for primary health care professionals (GPs, PNs and AHPs, pharmacists), including: New Hepatitis C Virus (HCV) treatments; New use of HIV medication as prevention; Responding to specific populations e.g. LGBTIQ; young people, People who inject drugs (PWIDs), people living with Blood Borne Viruses (BBVs), e.g. Hepatitis B Virus (HBV); Sexual transmissible infections (STIs). Description of Activity 2. Work in partnership with stakeholders (Local Health Districts, STIPU (NSW sexually transmitted infections program unit), ASHM and ACON) to facilitate a coordinated approach to build the primary health sectors capacity to prevent and manage STIs and BBVs by promoting: Shared Care Model (GPs and Albion St for HIV); S100 prescribing (HIV medication); Clinical placements at public sexual health clinics for GPs and PNs; Use of electronic appointments e.g. implementing Strata Health; Increasing the role of the Practice Nurse in sexual health e.g. implementing PDSAs for chlamydia in young people. 3. Encouraging Gay Friendly Practice through: Maintaining the Gay friendly GP List; Promoting uptake of the ASHM online learning module; Provision of safe sex resources to practices; Disseminating testing guidelines for syphilis, gonorrhoea, HIV; Sourcing and distributing news articles and the STIGMA newsletters. 4. Community education and mobilisation through: 21

22 Implementation of Stage 2 HIV Awareness in Chinese Community in St George region in partnership with SESLHD; Promoting Hepatitis B screening (fibroscan) in GP practices and communities surrounding Canterbury Hospital and RPA (divert patients away from public hospital liver clinics Canterbury and RPA); Investigate reducing stigma around BBVs and PWID by embedding positive speakers into medicine and nursing courses; Investigating targeting high risk populations for HCV and HBV e.g. newly released prisoners. 5. Increasing screening for STIs and BBVs: Investigate developing a PenCAT algorithm for clinical software to identify patients that require better management or screening for STIs and BBVs; Investigate possibilities for improving the capacity of GPs working with the Aboriginal community at La Perouse to detect STIs amongst the Aboriginal and Torres Strait Islander population : Capacity building for the primary care sector AIM Build primary care sector capacity to prevent, test, treat and manage STIs, HIV and Viral Hepatitis through a co-ordinated approach ACTIVITIES Face-to face training (CPD), clinical placements at sexual health services, in-services (practice lunches), and facilitates further training (prescriber and other higher level training). This program includes quality improvement activities, and may be submitted as PDSA (Plan Do Study Act) cycles to the RACGP for QICPD points, or may be eligible as standalone accredited activities. 22

23 The Sexual Health Education Program is in accordance with local, state and national strategies. Priorities include increasing GPs and Practice Nurse capacity to prevent, test, treat and manage STIs, HIV and Viral Hepatitis. Development of CESPHN data tracking for identification and tracking of GP Practices undertaking fibroscan testing Develop Hepatitis B indicators in the software Pen Clinical Audit Tool (CAT). Commission a SESLHD wide nurse led model of care for patients with chronic HBV and HCV through a range of General Practice focused programs to standardise screening, assessment, and triage for community-based antiviral treatment Recruit GPs to the trial of a cloud based program (PRISM) to assist primary health care providers in managing hepatitis C patients. EXPECTED OUTCOMES Increased knowledge among primary health care professionals on preventing, testing, treating and managing STIs, HIV and Viral Hepatitis At least 5 CPD events conducted Increased uptake of PDSA cycles among general practitioners from three to four S100 HIV prescribing course is taken up by two GPs per year. Hepatitis B indicators for Pen Clinical Audit Tool (CAT) developed Completed development of CESPHN data tracking for identification and tracking of GP Practices undertaking fibroscan testing As per agreement with SESLHD: o 2 mailouts to GPs on HCV treatments o 1 article on HCV treatments o Support CNC undertake practice visits to GPs to encourage them to identify and treat patients with HCV GPs recruited for the PRISM test of change pilot 2: STIs in priority populations 23

24 AIM Increase awareness among primary health care professionals on the inclusivity needs of transgender populations and the priority population of gay men and men who have sex with men in addressing STIs. ACTIVITIES Transgender health education session in GP practices. Trained speakers facilitate the session. As a result of this activity, GP practices can implement appropriate changes e.g. sign on sheet to capture transgender patients in a discrete manner. Transgender surveillance sign in sheet. This will collect data on how transgender information is currently recorded in primary care. As there is no data on transgender health in primary care, the results of this activity will identify service gaps and inform evidence-based strategies to improve transgender health. Maintain and promote the GP Gay friendly list Promote the Becoming More Gay Friendly in Your Practice Online Learning Develop content for the STIGMA newsletter and distribute to general practices biannually Provide condoms to general practice. Develop insert for condoms that has information on the Sexual Health Infolink and the phone number of the six publicly-funded sexual health clinics in metro Sydney Promote and distribute the Australian STI and HIV Testing Guidelines for Asymptomatic MSM national guidelines EXPECTED OUTCOMES A minimum of five Transgender health education sessions held in GP practices Collection of Transgender data on current recording practices in primary care Ensure GP Gay Friendly list is current and accurate Two STIGMA newsletters developed and distributed 2000 condoms distributed to general practice Condom insert developed with information on local sexual health services 24

25 3: Community education and mobilisation AIM Implement sexual health promotion strategies targeting identified priority population groups. ACTIVITIES An annual liver-check day (name to be confirmed) will be held at Exodus Foundation. SLHD Clinical Nurse Consultants will support the Exodus Clinical team (GP, nurses and practice staff) to undertake fibroscan testing, blood draws, consult and counsel clients, diagnose and prescribe the correct treatment. HIV testing education resources for the Chinese Community living in the St George region. EXPECTED OUTCOMES Inaugural Liver Check Day held at Exodus Foundation Minimum of 10 Fibroscans will be conducted during the Liver Check Day 500 Translated posters distributed across the St George area to GPs and other community and LHD services. 500 Translated wallet cards distributed across the St George area Additional translated posters at target venues (TAFE, Clubs, public toilets, Council venues) 4: Integration between PHC and LHD AIM To increase the number of GPs participating in the Shared Care Model to improve access to health services for HIV patients. ACTIVITY Albion Centre Shared Care model with primary care providers. This activity will support HIV patients maintain a relationship with a GP for non-hiv related health issues. The model will reduce the burden on Albion Centre and encourage HIV patients to receive appropriate care in primary care 25

26 settings. This activity includes co-leading the Secure Message Delivery (SMD): Reality Check project with Albion Centre. EXPECTED OUTCOME: Two GP practices will sign on to the Albion Centre Shared Care model. 5: Primary health care research in Chlamydia AIM To improve the management of chlamydia infection and PID in general practice by evaluating three separate interventions. ACTIVITY This is a 5-year research project, funded under the NH&MRC partnership grants. The University of Melbourne is the principle investigator in partnership with NSW and Victorian State Governments, as well as PHNs across NSW and Victoria. CESPHNs role will be to provide subject matter advice through participation on regular meetings and assisting the recruitment of practices Target population cohort EXPECTED OUTCOMES The major deliverable for the 5 year project will be an implementation plan for the roll out of a chlamydia and PID management program in general practice across Australia, specifically; 1. patient delivered partner treatment for chlamydia in general practice 2. mailed specimen collection kits for re-testing after treatment for a genital chlamydia infection in general practice 3. diagnosis and management tool on PID diagnosis rates in general practice Capacity building for the primary care sector; STIs in priority populations GP and Practice Nurses (also Practice staff in some instances) who see priority populations for: STIs - Aboriginal people, Gay and homosexually active men, Sex workers, Young people years of age 26

27 HIV - People with HIV, Gay and homosexually active men, Aboriginal people, Sex workers, People who inject drugs, Sex workers, People who inject drugs, People from culturally and linguistically diverse backgrounds Hepatitis C - People living with hepatitis C, People who inject drugs, especially new users, People in or recently in custodial settings, Aboriginal people, People from culturally and linguistically diverse backgrounds, and Young people who are at risk of injecting. Hepatitis B - people living with hepatitis B, mothers who are living with hepatitis B and their babies, people from culturally and linguistically diverse backgrounds particularly those born in countries with moderate to high rates of chronic hepatitis B infection, Aboriginal people; and people who inject drugs and other groups at increased risk of hepatitis B infection, particularly: household and sexual contacts of people living with hepatitis B; gay men and men who have sex with men; sex workers; and people in or recently in custodial settings. Priority settings (this is dependent upon IT infrastructure and availability of medical clinicians) GP clinics who see HCV patients Methadone dispensaries Specialist Homeless Services Drug and Alcohol Services Community education and mobilisation People who are experiencing homelessness or at risk of homelessness, People living with hepatitis C, People who inject drugs especially new users, Young people who are at risk of injecting, People from culturally and linguistically diverse backgrounds Aboriginal and Torres Strait Islander peoples Exodus staff and community Chinese community in the St George area GPs Integration between PHC and LHD Albion St 27

28 Consultation GPs Primary health care research in Chlamydia GPs Capacity building for the primary care sector CESPHN works in partnership with the following working groups: SESLHD GP partnership meeting SLHD Primary care advisory committee SESLHD Hepatitis Implementation meeting NSW PDSA network meeting STIMGA (STIs in Gay Men s Action Group) Committee meeting and clinician communication working party SLHD Hep B Action Group SESLH Hep B implementation committee meeting CESPHN community stakeholder round table consultation forum SNISH meeting (Senior meeting in Sexual Health) Regular communication with local service and education providers e.g. ASHM Regular communication with community organisations e.g. Positive life, Hep NSW, NUAA Working groups; SESLHD GP partnership meeting SESLHD Hepatitis Implementation meeting Participation from community organisation including Hepatitis NSW, NUAA PRISM online referral GP review meeting (one off meeting) Strata Health PRISM Working Group (hepatitis C) including NUAA, Hepatitis NSW Australasian Society for HIV Medicine (ASHM) Software company Pen CS to develop the CAT enhancements STIs in priority populations 28

29 STIGMA Group meets quarterly and STIGMA Clinicians Communication Working Group meets every two months. collaborating with The Gender Centre to deliver the education sessions. GP practices are engaged via practice visits, phone, , flyers and through quality improvement models. collaborating with the Kirby Institute at UNSW to develop the research methodology. CESPHN will generate a random sample of the catchment and engage those practices to identify how transgender patients are currently recorded. The Gender Centre will also be engaged in the project. Community education and mobilisation This activity is in collaboration with the Exodus Foundation and the local health district s hepatitis teams. Consultation with the HARP Unit, NSW Users & Aids Association, PHN drug and alcohol team and HARP Health promotion team. Supporting 3Bridges community lead and develop the resources; engage and focus test knowledge of HIV in Chinese community; engage and train community members to become champions ; develop resources with community champions; focus test resources; implementation strategy with local health district, Chinese media and local council Integration between PHC and LHD Working with Albion Centre and its IT team and HIV specialists; liaising with other PHN teams e.g. E- health team; engaging GP practices Collaboration Primary health care research in Chlamydia GPs, University of Melbourne Capacity building for the primary care sector; Integration between PHC and LHD 29

30 SESLHD- HARP unit, Public Health Unit- data and strategy; advisory committee, provide CNC, liaising with software vendors for integration of systems. SESLHD Services- D&A (Langton centre, Kirkton Rd Centre), Sexual Health and HIV (Sydney Sexual Health, Albion Centre, Short St, Kirkton Rd Centre), Liver clinics and infection disease departments (St George Hospital, Prince of Wales Hospital)- expertise, speakers, strategy, data, clinical placement providers. SLHD- HARP unit, Community Health- Health Promotion, Public health unit, advisory committee, provide CNC SLHD Services- Sexual Health and HIV (RPA Sexual Health), Liver clinics (RPA, Concord and Canterbury) Community organisations- positive life, NUAA, ACON, Hepatitis NSW, SWOP, Gender centre, Twenty10- data, expertise, speakers, client perspectives, resources NSW STI Programs unit- state wide coordination- contact with NSW Health, RACGP ASHM- peak body, education provider. POZHET- State-wide service- resources (when applicable) Multicultural HIV and Hepatitis service- State-wide- expertise, resources Health pathways- speakers, resources, information South West Local Health District advisory committee South West Primary Health Network advisory committee Wentwest Primary Health Network advisory committee Pen CS develop CAT platform STRATA Health- System build, GP trial (test of change) STIs in priority populations The following organisations are STIGMA members: - Sydney Local Health District (LHD) - South East Sydney LHD 30

31 - Northern Sydney LHD - ACON - Centre of Social Research, UNSW - The Kirby Institute, UNSW - Positive Life NSW - Australasian Society for HIV Medicine (ASHM) - NSW STIPU The Gender Centre The Kirby Institute, UNSW GP practices Community education and mobilisation Hepatology CNCs Hepatitis coordinator SLHD Exodus Foundation GP, nurses, practice manager CESPHN Drug and Alcohol team NSW Users & Aids Association Chinese Community members Chinese Australian Services Society advisory committee St George Chinese Services Network advisory committee Australian Council of Chinese Medical Association advisory committee Local Chinese media e.g. newspaper implementation Primary health care research in Chlamydia GPs, University of Melbourne Indigenous Specific Duration NO Capacity building for the primary care sector Critical success factor - Integration of PRISM with Medical Software 31

32 Q1- At least 2 CPDs delivered; Initial Planning and strategy for development of data tracking; promote S100 prescriber course; collaboration with PenCAT and clinicians in planning development of tool and identify funding sources Q2 At least 2 CPDs delivered; 2 clinical placements co-ordinated; Planning and strategy for development of data tracking; engage PenCAT and clinicians to develop tool Q3 At least 2 CPDs delivered; Test the model and data collection tool; completion of hepatitis B indicators in the software Pen Clinical Audit Tool (CAT); Two General Practices will be recruited for the test of change pilot Q4 PDSA cycles implemented; At least 2 CPDs delivered; Implementation phase of data collection tool and PenCAT tool; identifying future planning for this activity; two GPs will take up the S100 HIV prescribing course STIs in priority populations Q1 - Transgender inservice delivered; Q2 STIGMA magazine content will be developed and distributed; Transgender inservice delivered Q3 the Gay friendly provider list will be updated; Transgender inservice delivered; Evaluation phase of transgender activity Q4 STIGMA magazine content will be developed and distributed; Transgender inservice delivered Community education and mobilisation Critical success factor - Exodus Foundation re-engaging clinical staff Q1 - Negotiations and planning with LHD and Exodus Foundation; Engagement with GP practices for Chinese community campaign Q2 Liver check day Planning for implementation 32

33 Q3 - Planning & Promotion of Liver check day; The evaluation phase of Chinese community project Q4 - Delivery of Inaugural Liver Check Day at Exodus Foundation Integration between PHC and LHD Q 4 -Two GP practices will sign on to the Albion Centre Shared Care model Primary health care research in Chlamydia TBD Coverage Approach to market Decommissioning Capacity building for the primary care sector - whole PHN region STIs in priority populations - whole PHN region Community education and mobilisation - Inner west region SLHD and St George Area Integration between PHC and LHD - whole PHN region Primary health care research in Chlamydia - whole PHN region N/A N/A Funding from other sources 33

34 Proposed Activities Activity Title / Reference (eg. NP 1) Existing, Modified, or New Activity Program Key Priority Area NP 2.1 Aged Care NP 2.1 Aged Care - Sector Support through Education, Networking and Upskilling the aged care workforce. Modified (NP 2.1 from plan with addition of dementia friendly services; identifying needs and mapping of aged care services) (Medication management ends June 2017) Aged Care Ageing Section 4 Possible Options (pg ) Priority area Ageing; Education. Page 49. Provide education to health care professionals, RACF staff and community including retirement villages on topics such as advance care planning, my aged care, dementia. Needs Assessment Priority Area (eg. 1, 2, 3) Priority area Ageing; Dementia. Page 49. Partner with Dementia focused organisations to facilitate access to primary health care Investigate dementia friendly strategies for primary health providers, RACF and RV. Priority area Ageing, Falls Prevention and Dementia. Pages 48 and 49. Targeted falls prevention program Dementia friendly strategies within Residential Aged Care Facilities (RACFS) and Retirement Villages (RVs) Priority area Ageing; Referral pathways and service navigation. Page

35 Provide referral pathways and up to date care service navigation information to GPs and AHPs NP2.1 Aged Care 1. Provide Continuing Professional Development (CPD) to GPs, Practice Nurses and Residential Aged Care Facility (RACF) staff, which includes: Aged Care related topics could include: wound management, dementia management, mental health, anxiety, depression, medication management, and the My Aged Care (MAC) gateway Training for Practice Nurses and RACF staff to undertake advanced care and palliation planning with people with complex health care needs to reduce unnecessary hospitalisations and improve wellbeing at the end of life. Description of Activity 2. Promote healthy ageing by: Implementing three community based falls prevention programs to targeted populations. Two programs will be delivered in language to two CALD communities, and one program will be delivered to an Aboriginal community. These groups are often unable to access existing community based falls prevention programs such as Stepping On which targets the general population. Assisting Alzheimer s Australia roll out Dementia Friendly environments project in Sutherland and St George areas. A Dementia Friendly Community supports people with dementia, their families and carers to actively function as part of that community through designing physical environments with enhanced access, safety and navigation. Delivering community education to over 65 year old groups e.g. men s sheds, Probus, Rotary clubs, retirement villages and select CALD communities, on the Aged Care Reforms (My Aged Care) and advanced care planning. 3. Address medication management by: 35

36 Continuing to support Local Health Districts on two initiatives to increase appropriate use of medications and increase the numbers of home medication reviews (HMRs) undertaken. War Memorial Hospital is conducting a day rehabilitation project and Royal Prince Alfred Hospital is conducting a post discharge project. Continuing to support RACFs in the Halting Antipsychotic Use in Long Term care (HALT) project by promoting replacing the use of antipsychotics in people with dementia with alternative behaviour management techniques. Working with 10 RACFs to encourage medication reviews following hospital discharge of residents Continuing to support RACFs for medication transfer information for RACF patients following hospitalisation. Continuing to attend older persons working groups to promote medication information in the community. Continuing to promote quality use of medicine information/resources in English and other languages. Establishing relationships with major providers of Commonwealth Home Support Program (CHSP) to investigate possibilities for HMR. Continuing to work with RACFs in coordinating Regional Medication Advisory Committee (RMAC) meetings across the region 4. Improve service navigation and coordination between hospitals, GPs, ambulance services, NGOs and RACF and the aged community through: Modification and promotion of uptake of the Yellow Envelope transfer to hospital communication tool to ensure transfer of relevant patient information between RACFs, GPs, ambulance services and hospitals Provide individualised training to GPs and Practice Nurses in advanced care planning for all older people, focussing on newly diagnosed patients with dementia to improve effectiveness of plans within the hospital and ambulance services Work with LHDs to investigate effectiveness and appropriateness of frailty measures, with potential to implement into existing pathways and practice support tools 36