Primary Health Networks Core Funding. Primary Health Networks After Hours Funding

Primary Health Networks Core Funding Primary Health Networks After Hours Funding Activity Work Plan 2016-2018 COORDINARE South Eastern NSW This Activity Work Plan 2016-2018 was submitted to the Department of Health, after all internal organisational clearances and with the endorsement of the CEO and the Board of Directors of COORDINARE South eastern NSW PHN. 1

Table of Contents Introduction... 3 1.1. Strategic Vision... 7 1.2. Planned activities funded by the flexible funding stream under the Schedule Primary Health Networks Core Funding... 8 1.3. Planned core activities funded by the operational funding stream under the Schedule Primary Health Networks Core Funding... 25 2.1. Strategic Vision for After Hours Funding... 33 2.2. Planned activities funded by the Primary Health Network Schedule for After Hours Funding 34 Activties under 1.2: - Activities under 1.3: - Activities under 2.2: - NP 1 HealthPathways Coordination of Care Southern NSW NP 2 Illawarra Shoalhaven HealthPathways Program NP 3 Chronic disease surveillance NP 4 Capacity building with Aboriginal Community Controlled Health Organisations (ACCHOs) NP 5 Chronic disease prevention overweight and obesity NP 6 Community level interventions to improve immunisation and cancer screening participation NP 7 Service gaps in rural communities NP 8 Improved self-management of chronic disease NP 9 LHD Partnerships for PPH / Chronic Disease Management NP 10 Healthy ageing NP 11 Consumer Engagement NP 12 General Practice Research Scholarship NP 13 Workforce development NP 14 Service continuity and transition OP 1 Building capacity within primary care OP 2 Safety and Quality - Improving efficiency and effectiveness OP 3 Digital Health and use of technology OP 4 Meaningful use of data at a practice level OP 5 Clinical Networks / Clusters AH 1 Access to after-hours primary care in rural locations LHD partnerships AH 2 Equitable access to after-hours primary care in rural and urban locations medical deputizing services and alternatives AH 3 System redesign for after hours AH 4 Improving capacity of residential aged care facilities AH 5 Palliative care AH 6 Increase availability of after-hours support for consumers (and their carers) experiencing mental illness and alcohol and other drug issues AH 7 Promotion of after-hours options to increase consumer awareness of local options available 2

Introduction Overview The key objectives of Primary Health Networks (PHN) are: Increasing the efficiency and effectiveness of medical services for patients, particularly those at risk of poor health outcomes; and Improving coordination of care to ensure patients receive the right care in the right place at the right time. Each PHN must make informed choices about how best to use its resources to achieve these objectives. Together with the PHN Needs Assessment and the PHN Performance Framework, PHNs will outline activities and describe measurable performance indicators to provide the Australian Government and the Australian public with visibility as to the activities of each PHN. This document, the Activity Work Plan template, captures those activities. This Activity Work Plan covers the period from 1 July 2016 to 30 June 2018. To assist with PHN planning, each activity nominated in this work plan can be proposed for a period of 12 months or 24 months. Regardless of the proposed duration for each activity, the Department of Health will still require the submission of a new or updated Activity Work Plan for 2017-18. The Activity Work Plan template has the following parts: 1. The Core Funding Annual Plan 2016-2018 which will provide: a) The strategic vision of each PHN. b) A description of planned activities funded by the flexible funding stream under the Schedule Primary Health Networks Core Funding. c) A description of planned general practice support activities funded by the operational funding stream under the Schedule Primary Health Networks Core Funding. 2. The indicative Core Operational and Flexible Funding Streams Budget for 2016-2017. 3. The After Hours Primary Care Funding Annual Plan 2016-2017 which will provide: a) The strategic vision of each PHN for achieving the After Hours key objectives. b) A description of planned activities funded under the Schedule Primary Health Networks After Hours Primary Care Funding. 4. The indicative Budget for After Hours Primary Care funding stream for 2016-2017. Annual Plan 2016-2018 Annual plans for 2016-2018 must: provide a coherent guide for PHNs to demonstrate to their communities, general practices, health service organisations, state and territory health services and the 3

Commonwealth Government, what the PHN is going to achieve (through performance indicator targets) and how the PHN plans to achieve these targets; be developed in consultation with local communities, Clinical Councils, Community Advisory Committees, state/territory governments and Local Hospital Networks as appropriate; and articulate a set of activities that each PHN will undertake, using the PHN Needs Assessment as evidence, as well as identifying clear and measurable performance indicators and targets to demonstrate improvements. Activity Planning The PHN Needs Assessment will identify local priorities which in turn will inform and guide the activities nominated for action in the 2016-2018 Annual Plan. PHNs need to ensure the activities identified in the annual plan also correspond with the PHN Objectives; the actions identified in Section 1.2 of the PHN Programme Guidelines (p. 7); the PHN key priorities; and/or the national headline performance indicators. PHNs are encouraged to consider opportunities for new models of care within the primary care system, such as the patient-centred care models and acute care collaborations. Consideration should be given to how the PHN plans to work together and potentially combine resources, with other private and public organisations to implement innovative service delivery and models of care. Development of care pathways will be paramount to streamlining patient care and improving the quality of care and health outcomes. Primary Health Networks After Hours Funding From 2016-17, PHNs will have greater flexibility to commission programme specific services, having completed needs assessments for their regions and associated population health planning. PHNs are funded to address gaps in after hours service provision and improve service integration within their PHN region. Item B.3 of the After Hours Funding Schedule may assist in the preparation of the After Hours components of your Activity Work Plan (pages 12-15 of this document). Measuring Improvements to the Health System National headline performance indicators, as outlined in the PHN Performance Framework, represent the Australian Government s national health priorities. PHNs will identify local performance indicators to demonstrate improvements resulting from the activities they undertake. These will be reported through the six and twelve month reports and published as outlined in the PHN Performance Framework. Activity Work Plan Reporting Period and Public Accessibility The Activity Work Plan will cover the period 1 July 2016 to 30 June 2018. A review of the Activity Work Plan will be undertaken in 2017 and resubmitted as required under Item F.22 of the PHN Core Funding Agreement between the Commonwealth and all Primary Health Networks. Once approved, the Annual Plan component must be made available by the PHN on their website as soon as practicable. The Annual Plan component will also be made available on the Department of Health s website (under the PHN webpage). Sensitive content identified by the PHN will be excluded, subject to the agreement of the Department. 4

It is important to note that while planning may continue following submission of the Activity Work Plan, PHNs can plan but must not execute contracts for any part of the funding related to this Activity Work Plan until it is approved by the Department. Further information The following may assist in the preparation of your Activity Work Plan: Clause 3, Financial Provisions of the Standard Funding Agreement; Item B.3 of Schedule: Primary Health Networks After Hours Funding; Item B.4 of Schedule: Primary Health Networks Core Funding; PHN Needs Assessment Guide; PHN Performance Framework; and Primary Health Networks Grant Programme Guidelines. Please contact your Grants Officer if you are having any difficulties completing this document. 5

Our vision A coordinated regional health system which provides exceptional care, promotes healthy choices and supports resilient communities. Our purpose Supporting primary care in our region to be: comprehensive person-centred population-orientated coordinated across all parts of the health system accessible safe and high quality Our guiding principles evidence-based innovation collaboration and participation clinical engagement and leadership efficiency and value for money accountability and transparency 6

1.1. Strategic Vision COORDINARE believes that the challenge for Primary Health Networks is to reorganise health care delivery from a system which is fragmented, hospital-centric and designed to provide episodic treatment to one coordinated system, that better supports people with long term and complex conditions, and is financially sustainable. We recognise the critical importance of reorienting the whole health system from its current emphasis on episodic and acute care towards care that is delivered in the primary care setting and is well coordinated, i.e. the right care in the right place at the right time. Coordination of care is particularly important for an ageing population and the growing number of people with chronic and complex conditions in South Eastern NSW. To deliver our strategy, COORDINARE will work across three levels of intervention. These are: 1. Supporting general practice through: helping GPs better understand their own patient populations by unlocking the potential in their own patient data; working with GPs to improve the quality of care; and supporting GPs to help patients make necessary lifestyle changes and manage their own conditions. 2. Working within local communities by: commissioning services that are aligned to the needs identified through our needs assessments, for people who are at risk of poor outcomes; partnering with other agencies to reach people who are at risk but not accessing care; and working with GPs to consider the people in the wider population of the communities in which they practice. 3. System improvement by: bringing together general practice, hospitals and other providers to develop better ways to coordinate the care of patients who receive care from multiple providers; and working with Local Hospital Networks (LHNs) to use benchmarking and other performance data to focus system improvement efforts. 7

1.2. Planned activities funded by the flexible funding stream under the Schedule Primary Health Networks Core Funding Proposed Activities Priority Area (eg. 1, 2, 3) Chronic disease / Potentially Preventable Hospitalisations (Priority 1); Coordination (Priority 8) Activity Title / Reference (eg. NP 1.1) Description of Activity Indigenous Specific Duration Ongoing until June 30 2018 Commissioning approach NP 1 HealthPathways Coordination of Care Southern NSW Continue to promote, develop and document Clinical Care Pathways utilising HealthPathways tool. This will ensure GPs are better placed to help patients avoid going to hospital for conditions that can effectively be managed outside of hospital, and improve overall coordination of care across the region. The program covers patient journeys across 44,000sq km of rural regional NSW and cross border into the ACT. The program will also improve understanding of cross border jurisdictional requirements and efficiency when seeking to access and refer into tertiary care from multiple rural locations. The partnership between ACT Health, Capital Health Network and Southern NSW Local Health District is seeking to create coordination of care and effective transitions of care across the complex landscape by agreeing on, streamlining and promoting high volume, high value pathways. This work is being undertaken in collaboration a four way partnership involving Southern NSW Local Health District, Capital Health Network, and ACT Health and COORDINARE. No Southern NSW region and the ACT The commissioning approach will be a combination of purchased services and direct delivery. 8

Data source Project documentation; Website analytics Data collection has already commenced and will continue throughout the life of program 9

Proposed Activities Priority Area (eg. 1, 2, 3) Chronic disease / Potentially Preventable Hospitalisations (Priority 1); Coordination (Priority 8) Activity Title / Reference (eg. NP 1.1) Description of Activity Indigenous Specific NP 2 Illawarra Shoalhaven HealthPathways Program Duration Ongoing until the end of June 2018 Commissioning approach Data source Continue to promote, develop and document Clinical Care and Referral Pathways utilising the HealthPathways tool. This will ensure GPs are better placed to help patients avoid going to hospital for conditions that can effectively be managed outside of hospital, improving overall care coordination across the region. The target population are all of the approximately 400 000 residents who live in the Illawarra Shoalhaven region. This work is being undertaken in collaboration with the Illawarra Shoalhaven Local Health District, who are equal partners in the activity. There is shared governance for this activity and both organisations are contributing 50% of the funding for project management, technical infrastructure, clinical editing and clinical work groups for this initiative. ISLHD are also providing in kind input of specialist subject matter experts. No The Illawarra Shoalhaven region. The commissioning approach will be a combination of purchased services and direct delivery Project documentation Website analytics Data collection has already commenced and will continue throughout the life of program 10

Proposed Activities Priority Area (eg. 1, 2, 3) Chronic disease / potentially preventable hospitalisations (Priority 1) Activity Title / Reference (eg. NP 1.1) Description of Activity Indigenous Specific NP 3 Chronic disease surveillance Duration 1 July 2016 to 30 June 2018 Commissioning approach COORDINARE will: Continue the Sentinel Practices Data Sourcing (SPDS) project based on regular and ongoing collection and aggregation of general practice data that will enable COORDINARE to: - o enhance the population level monitoring of the prevalence of major chronic conditions and their associated lifestyle risk factors along with related clinical and service indicators, o provide an evidence-based framework to inform regional general practice quality improvement activities, o undertake chronic disease specific and regionally localised information reporting and knowledge dissemination for key stakeholders including but not limited to general practitioners and other primary care service providers o identify enablers and barriers to primary care information management as perceived by general practice staff and clinicians Undertake detailed analysis and reporting of the data collected by the SPDS project supplemented by comprehensive and updated Population Health Profiling to: - o create granular and regionally specific evidence-base of population health needs and service gaps o inform the service commissioning processes and primary care investment decisions for the catchment by identifying the most efficient and effective models of care for health consumers of the region, particularly those at risk of poor health outcomes In collaboration with University of Wollongong and participating general practices in the catchment No Entire PHN region Direct engagement of practices via incentive payments Data source Project documentation 11

Proposed Activities Priority Area (eg. 1, 2, 3) Aboriginal Health (Priority 4) Activity Title / Reference (eg. NP 1.1) Description of Activity Indigenous Specific Duration 1 July 2016 to 31 July 2018 Commissioning approach Data source NP 4 Capacity building with Aboriginal Community Controlled Health Organisations (ACCHOs) Local ACCHOs have identified a need for support to build their own capacity around data analytics and evaluation of organisation-specific initiatives. COORDINARE will partner with local ACCHOs and the university sector to increase capacity for data analysis, evaluation and benchmarking. This will allow shared and improved understanding of the impact, improvement opportunities, and future potential of interventions and investments. Alongside this, all flexible initiatives commissioned through ACCHOs will contain a resourced and supported evaluation component. In collaboration with local ACCHOs and tertiary institution. Yes Entire PHN region ACCHOs and other key stakeholders will be engaged to co-design an appropriate solution and help develop the specification. It is anticipated that procurement will then involve an approach to market. Contracted services will be monitored and evaluated through: development and monitoring of key performance indicators regular formal and informal communication between COORDINARE, any service provider and ACCHOs provisions in the contract and service specification reporting 6 and 12 monthly regarding implementation of the agreed services To be determined based on initiatives/s 12

Proposed Activities Priority Area (eg. 1, 2, 3) Chronic disease / potentially preventable hospitalisations (Priority 1) Activity Title / Reference (eg. NP 1.1) Description of Activity Indigenous Specific NP 5 Chronic disease prevention overweight and obesity Duration 1 January 2017 to 30 June 2018 Commissioning approach Data source COORDINARE will: approach the market to identify evidence based risk factor reduction approaches that are appropriate for local application, targeting people who are overweight or obese use our locally-generated evidence (ref NP3) to specifically target populations at greater risk, which will include people in small rural communities; people in low socio-economic areas; Aboriginal people; people in LGAs with high population prevalence of overweight and obesity give priority to initiatives that deliver sustained weight loss using new models of delivery and/or use technology to expand the reach of programs in a cost-effective manner. Actual initiatives to be commissioned will be determined through the approach to market and a codesign process. Determined via approach to market Not exclusively. However, programs targeting indigenous communities will be encouraged. Entire PHN region Modified competitive dialogue approach Contracted services will be monitored and evaluated through: development and monitoring of key performance indicators regular formal and informal communication between COORDINARE and the provider provisions in the contract and service specification reporting 6 and 12 monthly regarding implementation of the agreed services To be determined based on initiative/s undertaken 13

Proposed Activities Priority Area (eg. 1, 2, 3) Immunisation (Priority 2); Cancer Screening (Priority 3) Activity Title / Reference (eg. NP 1.1) Description of Activity Indigenous Specific Duration 1 January 2017 to 30 June 2018 Commissioning approach Data source NP 6 Community level interventions to improve immunisation and cancer screening participation COORDINARE will work with local communities to develop and implement localized prevention and screening activities. These include, but are not limited to, particularly low immunisation rates in the South Coast area and low participation in breast and cervical screening by CALD and Aboriginal women and will involve co-designed community level interventions. While specific interventions are yet to be defined, preliminary consultations have suggested community mobilisation as key enabler for improving immunisation rates, and health education and the development of culturally appropriate pathways and access to services as enablers for improving participation in screening for CALD and Aboriginal women. Local community organisations, LHD health promotion teams, BreastScreen Yes At risk groups across the region; South Coast SA3 (for immunisation activity) Commissioning will involve a modified competitive dialogue approach although it is recognised there may be few potential providers for some localised activity. Contracted services will be monitored and evaluated through: development and monitoring of key performance indicators regular formal and informal communication between COORDINARE and the provider relevant provisions in the contract and service specification campaign evaluation to be incorporated into all proposals and service agreements Australian Childhood Immunisation Register Breastscreen participation data 14

Proposed Activities Priority Area (eg. 1, 2, 3) Equity and access (Priority 7) Activity Title / Reference (eg. NP 1.1) Description of Activity Indigenous Specific NP 7 Service gaps in rural communities There are many communities within South Eastern NSW that experience gaps in health services due to their small and/or dispersed population, their rural location and socioeconomic disadvantage. COORDINARE will commission a limited number of service initiatives in these communities that aim to: improve management of chronic conditions for people at risk of poor health outcomes; increase access to surrounding services through improved coordination, collaboration, ehealth and/or workforce development; stimulate the market and/or move towards service sustainability. Service initiatives that are the responsibility of other agencies, eg Local Health Districts, or that have the potential to crowd out the private market, will not be prioritised. Determined by approach to market Duration 1 January 2017 to June 2018 No Rural locations throughout the catchment (SA 2 and 3) Commissioning approach Data source This will involve an approach to market. Selected services will be monitored and evaluated through: continued monitoring of key performance indicators regular formal and informal communication between COORDINARE and the provider relevant provisions in the contract and service specification six and twelve month reporting Six month and twelve month reports from providers 15

Proposed Activities Priority Area (eg. 1, 2, 3) Chronic disease / PPH (Priority 1) Activity Title / Reference (eg. NP 1.1) Description of Activity Indigenous Specific NP 8 Improved self-management of chronic disease Duration 1 January 2017 30 June 2018 Commissioning approach Data source COORDINARE will work with local primary care providers and consumers to identify and implement locally appropriate initiatives to increase consumers capacity to manage their own chronic conditions. A key focus will be the concept of patient activation, which includes patient knowledge, skills and confidence in managing their health and health care, as well as the likelihood that they will put these into action. Working with general practice and consumers, COORDINARE will identify and trial locally-acceptable approaches to measuring patient activation as well as approaches for improving activation for those patients who score in lower ranges. Evaluation of the activity will be used to determine sustainability and also viability for continued implementation beyond the initial duration. General practice, consumers, LHDs No Whole of region To be determined, but expected to be a modified competitive dialogue approach. Contracted services will be monitored and evaluated through: development and monitoring of key performance indicators regular formal and informal communication between COORDINARE and the provider provisions in the contract and service specification reporting 6 and 12 monthly regarding implementation of the agreed services Patient self-report Patient survey 16

Proposed Activities Priority Area (eg. 1, 2, 3) Chronic Disease/PPH (Priority 1) Activity Title / Reference (eg. NP 1.1) NP 9 LHD Partnerships for PPH / Chronic Disease Management Description of Activity COORDINARE currently has multiple partnership initiatives with the Illawarra-Shoalhaven and Southern NSW Local Health Districts relating to chronic disease management. Through joint planning initiatives that have commenced at an executive level with both LHDs, existing initiatives will be continued/completed and new initiatives established. will focus on locally appropriate models of integrated and coordinated care, for example: transitioning to the next iteration of the Connecting Care model in the Illawarra-Shoalhaven region; supporting implementation of NSW Health Integration Strategy projects, ie the Geriatrician in the Practice project (ISLHD) and the Eurobodalla Integration project (SNSWLHD); developing a joint Integrated Care Strategy in the Illawarra Shoalhaven; commencing joint planning to identify shared priorities for development of new models of care in Southern NSW. Indigenous Specific Duration 1 July 2016 to 30 June 2018 Joint analysis and planning is underway to better understand the profile of potentially preventable hospitalisations at a local level and agree on locally appropriate approaches to reducing these. Priorities under consideration: processes for early identification and risk stratification of patients; secure messaging of accurate medication records from hospitals to GPs; de-prescribing to reduce the negative consequences of polypharmacy; joint approaches to care coordination. Initiatives will focus on service redesign to improve efficiency and effectiveness of chronic disease management. LHDs, general practice, allied health providers No 17

Commissioning approach Data source Entire region Expected to be variations on service based commissioning (eg where services are being commissioned within the Connecting Care program) following a period of co-design. It is also expected that there will be opportunities for co-commissioning with LHDs. LHD data sets 18

Proposed Activities Priority Area (eg. 1, 2, 3) Ageing (Priority 6); Chronic disease prevention / PPH (Priority 1) Activity Title / Reference (eg. NP 1.1) NP 10 Healthy ageing A common theme throughout the needs assessment was the potential for PHNs and primary care to support healthy ageing in the community. Description of Activity Early consultation has pointed to: education and support for consumers, carers and primary care providers around advanced care planning and related issues, and improved access to prevention and/or re-enablement programs, particularly those relating to improving nutrition and preventing falls. Work in this area needs to be truly multi-sectoral and integrated. It will involve general practice, the aged care sector (both residential and community-based), home and community services, Local Health Districts as well as older people themselves and carers. As such, facilitated collaborative work is required to identify and agree on specific initiatives that could be commissioned to support older people to live independently for longer. Indigenous Specific Duration 1 January 2017 to 30 June 2018 Commissioning approach Data source Consequently, in this developmental activity, COORDINARE will work with consumers and other stakeholders to identify the most appropriate approaches to support healthy ageing and maximising the independence and self-care abilities of older people. Aged care service providers, community service providers, general practice, LHDs. No Entire PHN Soft market testing and modified competitive dialogue approach To be determined based on initiative/s undertaken 19

Proposed Activities Priority Area (eg. 1, 2, 3) Equity and access (priority 7) Activity Title / Reference (eg. NP 1.1) NP 11 Consumer Engagement Co-design and implement a consumer engagement strategy to ensure meaningful and robust consumer input across each stage of COORDINARE s planning and commissioning cycle. Description of Activity Our consumer engagement strategy will aim to enable patients to provide direct, timely feedback about their health related outcomes and experiences to drive improvement and integration of health care across or system. We will establish a range of mechanisms to encourage and increase opportunities for consumer input and co-design in health care system development. Indigenous Specific Duration July 2016 June 2018 Commissioning approach Influence the primary care sector to achieve general practice uptake of Patient Reported Outcome Measures (PROMs) and Patient Reported Experience Measures (PREMs) as part of the continuous quality improvement approach to accreditation. Community Advisory Committee, NSW Agency for Clinical Innovation, LHDs, relevant NGOs, general public, consumers, carers and regional service providers No Entire SE NSW PHN Region The commissioning approach will be direct engagement of specialised expertise and services. Data source Project documentation PROM / PREM survey results 20

Proposed Activities Priority Area (eg. 1, 2, 3) Chronic disease prevention / potentially preventable hospitalisations (priority 1) Activity Title / Reference (eg. NP 1.1) NP 12 General Practice Research Project Description of Activity The aim of this activity is to build research capacity of general practice in our region practice through engaging participants with general practice thought-leaders, while also addressing key PHN objectives. The competitive process will support a collaboration of GPs to complete a substantive research project focused on chronic disease management and/or co-ordination over a two year period under the supervision of the University of Wollongong s practice-based research network Illawarra and Southern Practice Research Network (ISPRN). It is intended that the research will be led by one or two GPs with the support of 4-6 other GP practices in the region (GPs, nurses and managers), providing research training and experience for a critical mass of general practice while also driving innovation in chronic disease care for the PHN. Indigenous Specific Duration July 2016 June 2018 Entire PHN region RA1, 2 and 3 Commissioning approach Data source Project documentation The project will facilitate administrative and academic support and training for the research project by UOW and direct research costs. The project will provide research mentoring and supervision by two senior GSM academics, administrative support and research assistance sufficient to complete the project. The successful project should be of sufficient scope to enable results to be published in a peer reviewed journal but also achievable by a new researcher within a two year timeframe. The activity will be undertaken in collaboration with the University of Wollongong s practice-based research network ISPRN. ISPRN has extensive experience in supporting novice GP researchers. UOW will supply all administrative and academic support for the project and supply to the PHN financial and progress reports. No UOW has been directly engaged, based on their previous experience and expertise. UOW will be contracted to undertake their roles via a commercial research contract. 21

Proposed Activities Priority Area (eg. 1, 2, 3) Activity Title / Reference (eg. NP 1.1) Description of Activity Indigenous Specific Chronic disease / Potentially preventable hospitalisations (Priority 1); Ageing (Priority 6); Coordination (Priority 8) NP 13 Workforce development Duration 1 July 2016 30 June 2018 Commissioning approach Data source Through targeted workforce development initiatives, COORDINARE will support the local health workforce, including general practice (GPs, practice nurses and practice managers) and allied health professionals to build on their existing knowledge, skills and attitudes in order to adapt to changing health needs. Workforce development initiatives will be aligned with the priority areas arising from our Baseline Needs Assessment, particularly chronic disease/potentially preventable hospitalisations, healthy ageing, and coordination of care. Activities will focus on translating new knowledge, skills and attitudes into practice locally and will be led by external clinical experts. Training providers, LHDs, professional colleges, universities No Whole of region The commissioning approach will be a combination of purchased services and direct delivery. COORDINARE CRM Proposed Activities Priority Area (eg. 1, 2, 3) Chronic disease / PPH (Priority 1); Equity and access (Priority 7); Coordination (Priority 8) Activity Title / Reference (eg. NP 1.1) NP 14 Service continuity and transition Description of Activity The former Medicare Locals introduced a range of clinical services across their respective regions that addressed local priorities identified at that time. COORDINARE will support the continuity of these services for a further six months while new initiatives are commissioned that are more closely aligned to the recent Baseline Needs Assessment. 22

Indigenous Specific Services covered under this activity include: malnutrition screening and falls prevention in residential aged care facilities (Illawarra-Shoalhaven); specialist allied health services for clinically at risk patients in Nowra; dietetics outreach in the Shoalhaven; healthy lifestyles and health promotion (Southern NSW); improving access for rural young people in the southern Shoalhaven; podiatry, physiotherapy and men s health services in Gunning; youth services in Eden; access to Aboriginal primary health services for people in Wallaga Lake, Bega and Eden; neurological nursing services in the Shoalhaven. NB: Mental health services that were previously funded through the Core Flexible Fund have been shifted to mental health flexible funds to be incorporated into the regional mental health service planning. Affected services are: Family Counselling and Support Services in Bombala and Snowy River Shires (activity 3C2 in the 2015-16 Establishment and Transition Plan); and Mental Health Nursing, Mental Health Education (i.e. Mental Health First Aid) and Community Mental Health Services in Southern NSW (part of activity 3B1 in the 2015-16 Establishment and Transition Plan) Service providers currently delivering under this activity will be actively encouraged to participate in the commissioning of new, more appropriately targeted services, where relevant. Services will be required to provide a transition out plan and will be actively supported through the decommissioning process. Existing service providers Duration 1 July 2016 to 31 December 2016 Commissioning approach No Catchment wide This will involve a six month extension of current contracts. Contracted services will be monitored and evaluated through: continued monitoring of key performance indicators regular formal and informal communication between COORDINARE and the provider relevant provisions in the contract and service specification six month reporting 23

Data source Six month reports from providers 24

1.3. Planned core activities funded by the operational funding stream under the Schedule Primary Health Networks Core Funding Proposed general practice support activities Activity Title / Reference Description of Activity OP 1 Building capacity within primary care The primary care sector is under strain, working within a fragmented health system and managing a growing population with more complex chronic health needs. Further capacity is required within primary care in order for practices to remain sustainable and to provide the most effective and efficient care, particularly for population groups most at risk. COORDINARE is committed to building capacity within primary care. Currently whilst the majority of general practices in the region are accredited, COORDINARE recognises the importance of accreditation as a benchmark of quality. COORDINARE will continue to encourage and offer support when required for practices to obtain and maintain accreditation. Building on this, COORDINARE plans to partner with the University of Queensland and roll out the Primary Care Practice Improvement Tool (PC-PIT) to interested practices in the region. The PC-PIT is a validated tool which practices can complete which assesses known elements of organisational capability including patient-centred care, leadership, organisation and clinical governance, communication for staff and patients, change management, performance management and information technology usage. This tool can act as a primer for accreditation, identifies areas for quality improvement, can direct PHN staff to practices requiring more intensive support and can facilitate the transition to Patient Centred Medical Home (PCMH) model of care for more highly functioning practices. Practices will also have access to training and excellent online resources to support quality improvement across a range of different business models. This collaboration will provide learnings on how the PC-PIT process can fit into existing PHN QI programs and contribute to the development of a framework for other PHNs to adopt. 25

Duration July 2016-June 2018 Expected Outcome Finally further resources and training, again in collaboration with the University of Queensland, will be provided to interested high performing practices to further develop the essential building blocks of the PCMH model. Finally further resources and training, again in collaboration with the University of Queensland, will be provided to interested high performing practices to further develop the essential building blocks of the PCMH model. This activity is a collaboration between COORDINARE and the University of Queensland COORDINARE will offer all practices in the SE NSW PHN region the opportunity to participate in capacity building activity. Maintain and incrementally increase the proportion of accredited practices in the region Target a minimum of 25 practices to participate in the PC-PIT initiative Target high performing practices from PC-PIT to participate in PCMH capacity building 26

Proposed general practice support activities Activity Title / Reference OP 2 Safety and Quality - Improving efficiency and effectiveness To ensure safety and improve quality of care across the primary care sector COORDINARE will facilitate general practice based quality improvement activities working to: Improve childhood immunisation rates Improve bowel, breast and cervical cancer screening rates Increase uptake of preventative health checks Description of Activity Promote safe use of medicines and medication review processes Other priority chronic disease areas including mental health Work will also support the use of effective local clinical care pathways by general practice with the promotion of the two regional HealthPathways programs. This activity will be led by COORDINARE, who will work with general practice, Local Health Districts and key stakeholders to achieve improved outcomes. Duration July 2016 June 2018 Entire SE NSW PHN region, with a particular focus on areas of need Expected Outcome In the short term the aim to engage and continue to work with 50% of practices in population health based quality improvement activities with incremental increases thereafter In the longer term the aim is that activity will contribute to positive change for selected regional indicators e.g. Cervical screening 27

Proposed general practice support activities Activity Title / Reference Description of Activity OP 3 Digital Health and use of technology Duration July 2016 June 2018 Meaningful use of technology is seen to be a key enabler in the provision of effective care coordination, particularly for those most at risk of poor health outcomes. Activities to continue to improve the capacity of the primary health sector in relation to their use of technology include: The promotion of meaningful use of My Health Record to key stakeholder groups that include general practice staff, community pharmacists, residential aged care facility staff, Local Health District staff and consumers, in order to streamline the flow of relevant patient information across the local health provider community. Increasing the use of secure messaging technology between health service providers, which in turn will streamline referral pathways and contribute to consumers receiving the right care in the right place at the right time. Driving efficient effective and coordinated care for rural consumers by working with regional and tertiary service providers to expand use and understanding of available telehealth technology. Work with the primary care sector to document existing telehealth capacity including an audit of capacity and projected system requirements. Source education to upskill regional providers and develop functional service linkages between regional providers involved in coordination of patient care, and more broadly with tertiary centres of excellence. This activity will be led by COORDINARE, who will seek to engage key stakeholders listed above in order to implement specific actions. Entire SE NSW PHN region Telehealth activity will focus on RA2 and RA3 areas within SE NSW PHN region Expected Outcome My Health Record 28

Achieve 15% population of COORDINARE s catchment registered for a My Health Record (Currently 10.72%) Maintain current participation (and compliance) with ehealth Practice Incentive Program across COORDINARE s catchment (currently 68%) Secure Messaging Increase in the number of providers general practice can refer to via secure messaging Telehealth Increase general practice capacity to engage with telehealth services where available 29

Proposed general practice support activities Activity Title / Reference Description of Activity OP 4 Meaningful use of data at a practice level Utilsing data from primary care practices is extremely valuable in determining not only the prevalence of disease and risk factors of the practice population but also ensuring that the care being provided is evidence based and achieving improvements in health outcomes. In order to maximise the use of meaningful data and to drive evidence-based quality improvement in primary care, COORDINARE has invested in the CAT Plus suite of tools and has rolled-out an empirically validated methodology of using primary care data though the Sentinel Practices Data Sourcing (SPDS) project. Under this project the CAT Plus tool has been made available to all eligible practices and primary care practitioners. This allows practices to build capacity by first establishing clean data, and then utilising the tools to understand their practice population s health needs while contributing to the overall catchment s population health and primary care planning initiatives. While the chronic disease and risk factor monitoring activities will be undertaken under the SPDS project (see NP2 Chronic disease surveillance); under this activity: - Primary care staff (particularly clinicians) will be encouraged, supported and assisted to use the Topbar tool (part of the CAT Plus suite) at an individual level in order to correct missing and incomplete sections of a patient s electronic health record at point of care. This can potentially improve the overall effectiveness of routine primary care consultations. Practices will be assisted in understanding their own data using the CAT4 tool (part of the CAT Plus suite) and using that information to improve the quality of care for practice population specific indicators through generating list of patients that fall into selected population target groups and then proactively implementing recalls and reminders through their electronic medical record software systems. Through this activity COORDINARE aims to change practitioner and primary care staff behavior in delivering more proactive care. Additionally improving data awareness will assist in both internal and external quality improvement initiatives and in practices developing a population health view of primary healthcare service delivery. COORDINARE will work in collaboration with the SPDS project team and participating practices 30

Duration Expected Outcome July 2016 - ongoing This tool and associated SPDS project training has been offered free of charge to all eligible practices in the SE NSW PHN. Currently more than 80 practices have consented to partake in the SPDS project and have the CAT Plus suite of tools installed. The goal of this activity is to improve the primary care sectors capacity to understand their population health data and consequently provide more proactive care. Over the next year the aim is to: Maintain the number of practices participating in the activity Continue to increase the level of participation by practices in the activity Continue to encourage uptake by other practices through various channels 31

Proposed general practice support activities Activity Title / Reference Description of Activity Duration Expected Outcome OP 5 Clinical Networks / Clusters COORDINARE will work with GPs and other health service providers across the region with a specific focus on appropriate workforce support and development. This will be achieved through establishing peer learning networks, professional clusters and targeted learning opportunities that link quality improvement initiatives with education and peer networking. Shared learnings about evidence informed practice and innovative system improvement approaches will contribute to a sustainable primary care workforce. In addition strengthening of communication pathways between primary and secondary care providers will create linkages for enhanced care pathways and improved coordination of care. COORDINARE will also reinforce these network links with Clinical Councils and use these channels to diffuse information more efficiently. Sector wide GP clusters Practice manager networks/workshops Practice nurse networks/workshops July 2016 ongoing Entire SE NSW PHN Region GP clusters operating across 12 subregions provide feedback to Clinical Councils which in turn can inform planning and commissioning 50% practice participation at network meetings/workshops with incremental increase over time 32

2.1. Strategic Vision for After Hours Funding COORDINARE s strategic vision for after hours funding is informed by our overall vision. The after hours programme will facilitate a coordinated regional health system that is comprehensive, person-centred, population-orientated, accessible, safe and high quality. The development of initiatives will be driven by COORDINARE s guiding principles and will be evidence-based, innovative, efficient and present value for money., participation and clinical engagement will ensure accountability and transparency. COORDINARE s vision for after hours initiatives recognizes that services provided by the Practice Incentive Program After Hours Incentive (aimed at general practices) should not be duplicated. As such, our primary approach is on commissioning changes in systems and structures, both in and after hours, to promote improved access to timely primary care across the region. A secondary approach is on specific initiatives to address particular gaps, such as use of Medical Deputising Services. Key themes will be: Accessibility to services particularly in rural communities Increasing efficiency and effectiveness of after hours primary health care Reducing emergency department presentations Developing and supporting patient-centred care models Facilitating coordination of care in hours and after hours Embedding after hours planning and service delivery as an integral part of co-design and commissioning. 33

2.2. Planned activities funded by the Primary Health Network Schedule for After Hours Funding Proposed Activities After Hours Priority Area (eg. 1, 2, 3) After Hours Activity Title / Reference (eg. AH 1.1) Description of After Hours Activity Lack of access to after-hours services particularly in rural areas and also particularly impacting families with young children, aged care residents and palliative care patients (Priority 1) Capacity issues in Shoalhaven LGA during after hours and seasonal peaks (Priority 3) AH 1 Access to After Hours primary care in rural locations LHD partnerships COORDINARE will: Facilitate a collaborative partnership with ISLHD to decrease the pressure on the Shoalhaven District Memorial Hospital ED. Activities will include: o Designing and implementing a trial, including pathways, protocols and risk assessments for offering patients the choice of attending the co-located general practice o Applying an evaluation framework to evaluate effectiveness. Work with GP s in the broader Shoalhaven region to reconsider existing after hours arrangements and trial alternative approaches. Collaborate with SNSWLHD to test the feasibility of co-commissioning solutions such as telehealth in small rural communities, where Emergency Departments are staffed by GP VMOs or without medical coverage. Participate in SNSWLHD planning processes for the redevelopment of both Goulburn Hospital and Health Services and Yass Health Service, where after hours service provision has been identified as priority consideration, with a view to co-commissioning solutions. Consultation and collaboration with key stakeholders is an essential component of implementing these initiatives and will include a primary focus on the PHN, LHDs and GPs other key stakeholders will include ACCHOs, Ambulance NSW, and Pharmacists 34

Duration July 2016-June 2017 Commissioning approach Data source Entire PHN region, with a primary focus on rural communities The commissioning approach will vary according to the nature of the initiatives and is expected to involve both direct approaches where specific hospitals and health services are involved, and wider approaches to the market for other solutions such as telehealth. Commissioned services will be monitored and evaluated through: Developing performance indicators and regular reporting for monitoring during the course of the trial A final report will detail successes, difficulties and possible solutions/areas for improvement. Communicating regularly with the trial participants MBS data (subject to availability) LHD ED data Feedback from patients and providers 35