Updated Activity Work Plan 2016-2018: Integrated Team Care Funding The Activity Work Plan template has the following parts: 1. The updated Integrated Team Care Annual Plan 2016-2018 which will provide: a) The strategic vision of your PHN for achieving the ITC objectives. b) A description of planned activities funded by Integrated Team Care funding under the Indigenous Australians Health Programme (IAHP) Schedule. Central and Eastern Sydney PHN When submitting this Activity Work Plan 2017-2018 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 to <name of Grant Officer> via email <email address> on or before 17 February 2017 1
Overview This updated Activity Work Plan covers the period from 1 July 2016 to 30 June 2018. To assist with PHN planning, each new activity nominated in this work plan should be proposed for a period of 12 months. The Department of Health will require the submission of a new or updated Activity Work Plan for 2018-19 at a later date. 1. (a) Strategic Vision for Integrated Team Care Funding CESPHN has an ongoing commitment to improving the health outcomes and addressing the health needs of more than the 15,466 identified Aboriginal and Torres Strait Islander community members regularly residing in the Central and Eastern Sydney area. To have a positive contribution to improving the health of our community we will work to enhance collaboration and partnership with local health care professionals and services in the region. New partnerships and opportunities to improve health and health care will be explored and developed. Health care will be provided in the right place, at the right time by the right health services providers. We will strive to ensure that clients of services will have access to culturally appropriate resources and information and be educated to make informed decisions about their ongoing health care and that Aboriginal and Torres Strait Islander community members have equity in access to health care services. People who are disadvantaged will be provided with support and assistance to access services where necessary. Integrated Team Care program plans and actions will be well informed, from a combination of evidence based research and meaningful, genuine community and stakeholder consultation, codesign, decision making and input. Services will be of a high-quality, offering value for money and culturally appropriate, safe and sensitive. Services will be provided in an efficient, sustainable and cost effective manner and will be monitored, evaluated and remodelled as required. CESPHN will ensure any commissioning of Integrated Team Care direct services is undertaken through a transparent, accountable and open process. The Integrated Team Care workforce will be valued, consulted and included in the development and implementation of initiatives. Personal and professional development opportunities will be provided to enable staff to meet ongoing changes in the health system. Health care providers in the CESPHN region will be supported with Indigenous workforce development, training and capacity building. CESPHN will foster relationships with LHDs, ACCHOs, NGOs and ACCOs to develop strategies to reduce the current number of avoidable hospital admissions by Aboriginal and Torres Strait Islander patients. A dedicated focus of our work in Integrated Team Care will be reviewing, identifying, addressing and responding to the changing needs identified in the Needs Assessment, in particular, those of our considerably younger age profile Aboriginal and Torres strait Islander residents and higher proportion of identified Indigenous Australian population in the 50 54 year age group. 2
By creating a culturally competent workforce across our organisation, whilst promoting a CESPHN endorsed Indigenous Employment Strategy we will aim to help build the local Indigenous health workforce and positively influence, provide leadership and guidance to local mainstream primary care providers across the region. Our vision for the future of the Integrated Team Care Program is realising nothing less than the full potential of our primary care providers and to be recognised for positively contributing and influencing a demonstrable improvement in the health outcomes of local Indigenous community members, enabling access to timely and affordable, culturally competent primary health care services. 3
1. (b) Planned activities funded by the IAHP Schedule for Integrated Team Care Funding Proposed Activities ITC transition phase 2016-2017 There is currently no identified organisation that has the capacity, experience and reach to deliver the ITC care coordination and outreach services across the entire CESPHN district. CESPHN will be undertaking service co-design consultations in July/August before a direct/targeted commissioning approach is made, potentially to multiple service providers across the region (subject to market analysis, testing and current availability of appropriate services). The EOI process for commissioning will be completed by end of September 2016 with transitional arrangements expected to be fully completed in time for 1 January 2017. During this time the outreach and care coordination will continue to be provided by CESPHN employees. Workforce capacity building and support will be required during the transition phase, to assist the development of alternative services to be able to meet the identified needs of the ITC program and achieve the KPIs. Transitional arrangements for client care, consent for potential sharing of records and communication strategies on the changes being implemented to both service providers and community will be undertaken by CESPHN prior to 1 Jan 2017. The practice support and promotion aspects of the program will continue to be delivered by CESPHN to reinforce and draw on the extensive experience of the staff and organisational relationships that are already established with the local health service providers. 2017-2018 CESPHN currently continues to directly deliver all aspects of the ITC program. The commissioning arrangements for the elements of care coordination and outreach work will be fully transitioned by the end of March 2017. Delays were experienced by applicant organisations during the RFP submission process and an extension was granted by CESPHN to the organisations to submit/resubmit their application. As a result of the end of year compulsory holiday period and recruitment freezes/hr department closure within the applicant organisations during this time a delayed handover has occurred within the approved commissioned organisations, the transition within the initially proposed timeframe has been unavoidably delayed. An application to DoH was made in November 2016 to extend completion of the transition process to March 2017. The extension approval was received. CESPHN continues service delivery including; 4
primary health care provider support indigenous health initiatives promotion stakeholder engagement and liaison referral pathway development and maintenance quality improvement activities and support care coordination Aboriginal outreach work support cultural awareness training and education workforce development and support service evaluation The practice support initiative, promotion, stakeholder engagement, quality improvement activities and evaluation will continue to be delivered by CESPHN which builds on the trust and report already established with the local health service providers. Start date of ITC activity as fully commissioned Is the PHN working with other organisations and/or pooling resources for ITC? If so, how has this been managed? 2016-2017 1 July 2016 2017-2018 31 st March 2017 2016-2017 No definite plans to collaborate with any other PHNs at this stage. Northern Sydney PHN will be involved in the co design consultations for CESPHN and may decide to collaborate depending on the outcomes of the consultation process. 2017-2018 N/A Service delivery and commissioning arrangements Decommissioning Decision framework Nil Known 2016-2017 Aboriginal Health is a Departmental priority and is identified as one of the top fifteen priorities in the CESPHN baseline needs assessment. A number of possible options were outlined in the BNA which address the identified needs and gaps prioritised. A comprehensive consultation process was undertaken during the needs assessment process which included: Six consultations held in February 2016 across the region (Arncliffe, Maroubra, Menai, Burwood, Redfern, Riverwood) and attended by 225 participants. Invitations were distributed widely to AMS Redfern, local Aboriginal community controlled organisations (Guriwal Aboriginal Corporation, Wyanga Aboriginal Aged Care, Kurranulla Aboriginal Corporation, La Perouse and Metropolitan Aboriginal Land Council, Tribal Warrior, National Centre for Indigenous Excellence, NGOs currently working with community members, SLHD/ SESLHD staff (Aboriginal Unit Managers and Aboriginal Liaison Officers) and Sydney Children s Hospital 5
representatives, local community members and some additional representatives including NSW Police (Maroubra) Aboriginal Liaison Officer (ALO) and Matraville High School Aboriginal Education Officers (AEOs). Further consultations were held with the La Perouse Community Alliance, attended by a representative of the Department of Aboriginal Affairs and in March with the La Perouse community members, community controlled organisation representatives and local council Diversity Officers (in total 27 participants). An additional consultation was held with the Ngala Nyanga Mai young parents group (12 participants). The outcomes of this consultation process highlighted the following: The need for more Aboriginal workers and outreach services to meet the needs of the community. The need to have more Aboriginal staff available in mainstream health services to support cultural safety. Community members expressed a desire to have more services available to them in their home or local health care provider settings. Currently hospital based Aboriginal staff provide limited outreach for in-home services and are not delivering these services across the entire CESPHN region. Transport continues to be a significant barrier for members of the community and has been since the inception of the Closing the Gap programme. Having more outreach services available will help to overcome this barrier in conjunction with the availability of transport assistance through the supplementary services component of ITC. Community satisfaction was expressed with current Indigenous services being provided by the CESPHN, though there was an expressed need for more support for those who do not meet the criteria of the CCSS program. Need for enduring community consultation through the lifecycle of a policy or program and meaningful engagement with the PHN. Additional consultations were undertaken with Clinical and Community Councils and CESPHN staff around the priority options for Aboriginal health. Common priorities relevant to this model included, o Increased awareness and availability of cultural education for health professionals o Need for more identified positions o Consideration of social and cultural determinants o o Need for more outreach services Need to engage with communities and involve them in decision making process and empowering communities CESPHN Needs Assessment has therefore highlighted that there is support for more Aboriginal workers and outreach services to meet the needs of the community and to have more Aboriginal staff available in mainstream health services to support cultural safety. During consultations community members have expressed a desire to have more services available to them in their home or local health care provider settings. Services with Aboriginal staff currently provide limited outreach 6
for in-home services and are not delivering these services across the entire CESPHN region. Transport has continued to be a significant barrier for members of the community since the inception of the Closing the Gap programme. Having more outreach services available will help to overcome this barrier in conjunction with the availability of transport assistance through the supplementary services component of ITC. Our proposal is for a commissioned team of a minimum of four (4) Aboriginal and Torres Strait Islander Outreach Workers and four (4) Care Coordinators to meet the requirements of the ITC schedule and respond to the priority of maintaining and building on the existing Aboriginal workforce, identified by key stakeholders. To support this model, an IHPO role each responsible for the distinct geographical communities in the CESPHN area will be employed and ideally co-located at CESPHN. The role of the IHPO is to provide policy and leadership by administering the supplementary service funding requests, overseeing the commissioned service, facilitating access to endorsed cultural competency training, directing and managing the program promotional work with regional primary health care professionals and ensuring integration of care with relevant service providers. The objectives of the ITC program will be addressed by the proposed options, and these will form the basis of the work plan for the Outreach Workers and Care Coordinators. Current market analysis identified that the distribution of Aboriginal health workers who are able to be mobilised to the community are often not in areas with higher proportions and numbers of Aboriginal people. This includes areas such as Botany Bay, Marrickville, and Randwick (former LGAs), Sydney and Sutherland Shire LGAs. There is currently; Royal Hospital for Women 1 x Aboriginal Education Officer Sydney Children s Hospital 2 x Aboriginal Education Officers Prince of Wales Hospital 4 x Aboriginal Health Education Officers (2 current vacancies) 2 x Aboriginal Sexual Health Education Officers 2 x Mental health workers 1 x Aboriginal Liaison Officer La Perouse Community Health 2 Aboriginal Dental Assistants Royal Prince Alfred 2 x Aboriginal Health Workers 1 x Health Promotion Officer 7
St Vincent s Hospital 1 x Aboriginal Liaison Officer 2 x Aboriginal Health Workers Sutherland/ St George Hospital 1 x Aboriginal Health Education Officer (vacant) 1 x Aboriginal Liaison Officer (vacant) Benevolent Society Senior Aboriginal Practitioner 1 x Aboriginal respite and carers program assistant 1 x Aboriginal Community Engagement Facilitator 1 x Aboriginal Mental Health Facilitator Aboriginal Medical Service unable to accurately quantify at this time. The presence of more Aboriginal health/ outreach workers in the community working with patients outside of those that are hospital admitted, has been requested by community members and organisations in all areas. In general, the community members involved in the consultations were happy with the current services being offered by CESPHN and did not nominate for any change to be made. To enable an effective communication model with the staff in the PHN undertaking the IHPO role. Offers professional and peer support to clinical staff in the program and supports development of outreach staff Allows for shared work planning across the region whilst tailoring it to specific community needs in line with needs assessment input. The proposed model of delivery and commissioning activities will be refined after two further consultations with key stakeholders and community providers, planned for July/ August. There are a number of other commissioned activities for Aboriginal and Torres Strait Islander communities outlined in the Operational and Flexible, Mental Health and Drug and Alcohol Plans. 2017-2018 Our proposal is for a commissioned team of a minimum of four (4) Aboriginal and Torres Strait Islander Outreach Workers and four (4) Care Coordinators to meet the requirements of the ITC schedule and respond to the priority of maintaining and building on the existing Aboriginal workforce, identified by key stakeholders. To support this model, an IHPO role each responsible for the distinct geographical communities in the CESPHN area will be employed and ideally co-located at CESPHN. The role of the IHPO is to provide policy and leadership by administering the supplementary service funding requests, overseeing the commissioned service, facilitating access to endorsed cultural competency training, directing and managing the program 8
promotional work with regional primary health care professionals and ensuring integration of care with relevant service providers. Concerns were raised with a lack of continuity and possible trust issues in transferring the service delivery over to new providers. Local organisational and community representatives were advocating strongly to be fully informed and involved in the design process of the potentially commissioned services through alternate organisations. A lengthier transition phase over six months is preferred to ensure key stakeholders and community representatives are offered sufficient time to have input into the process. Indigenous sector engagement CESPHN Needs Assessment Report Nov 2016 Consumer Input- Community consultations including a co-design consultation The outcomes of consultations highlighted the following elements that need to be considered and included into commissioned services for this Activity. i. The need for more Aboriginal workers and outreach services to meet the needs of the community. ii. The need to have more Aboriginal staff available in mainstream health services to support cultural safety. iii. Community members expressed a desire to have more services available to them in their home or local health care provider settings. Currently hospital based Aboriginal staff provide limited outreach for in-home services and are not delivering these services across the entire CESPHN region. iv. Transport continues to be a significant barrier for members of the community and has been since the inception of the Closing the Gap programme. Having more outreach services available will help to overcome this barrier in conjunction with the availability of transport assistance through the supplementary services component of ITC. v. Community satisfaction was expressed with current Indigenous services being provided by the CESPHN, though there was an expressed need for more support for those who do not meet the criteria of the CCSS program. vi. Need for enduring community consultation through the lifecycle of a policy or program and meaningful engagement with the PHN. To address community needs, commissioned providers will be encouraged to include more outreach services available to overcome this barrier in conjunction with the availability of transport assistance through the supplementary services component of ITC. 2017-2018 Improve and expand on outreach services in Aboriginal community based and controlled organisations with a view to work in partnership with community organisations to expand the reach and effectiveness of outreach programs, including: o School based health promotion programs (targeting children with an increased focus on high school age children in accordance with the CESPHN CNA and their extended families) 9
o Community based health promotion programs Work collaboratively with Aboriginal Liaison Officers and Aboriginal Health Education Officers to improve seamless transition between acute and primary care setting for Aboriginal and Torres Strait Islander patients Facilitate quarterly health promotion events in collaboration with local Aboriginal Community Controlled Organisations e.g. Elders Olympics in March 2017 Provide linkages to community members with culturally appropriate; smoking cessation programs drug and alcohol programs (particularly for youth) mental health initiatives Develop prevention services and programs in collaboration with LHD Aboriginal team(s) and AMS staff wherever possible Initiate and support community driven programs with community groups e.g. for provision of healthy lifestyle and health promotion information Expand on Schools Aboriginal Health Program aimed at improving health literacy and providing access to a range of service providers Strengthen partnerships with justice health programs and explore ways to better support Aboriginal people on release from the justice health system. Continue to engage Aboriginal Community Controlled Organisations and community representatives in program co-design Continue to include and promote Aboriginal and Torres Strait Islander representation on CESPHN Advisory groups Invite input and consult with the Indigenous health sector to the PHN s Reconciliation Action Plan Decision framework documentation Description of ITC Activity ITC Workforce Yes As per previous Activity submitted (no changes) 2016-2017 4 x Care Coordinators - to be commissioned to either mainstream or AMS 4 x Aboriginal Outreach Workers - to be commissioned to either mainstream or AMS 3 x IHPO- to be engaged by the PHN (to accommodate regional diversity with Indigenous communities and services) 1 x Admin/intake/ contract management - to be engaged by PHN 2017-2018 4 x Care coordinators to be employed by commissioned organisation(s) 4 x Aboriginal outreach workers to be employed by commissioned organisation(s) 1 x Contract manager to be employed by PHN 1 x Intake/ admin office to be employed by PHN 3 x program officers to be employed by PHN 10
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