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 Annual Plan 2016-2018 Annual Operational and Flexible Funding Streams Budget 2016-2017 After Hours Budget 2016-2017 Perth South PHN Version 2.0 August 2016

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 Commonwealth Government, what the PHN is going to achieve (through performance indicator targets) and how the PHN plans to achieve these targets; be developed in consultation with local communities, Clinical Councils, Community Advisory Committees, State/territory governments and Local Hospital Networks as appropriate; and articulate a set of activities that each PHN will undertake, using the PHN Needs Assessment as evidence, as well as identifying clear and measurable performance indicators and targets to demonstrate improvements. 2

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. 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. 3

1 (a) Strategic Vision WA Primary Health Alliance (WAPHA) exists to facilitate a better health system for all Western Australians that achieves improved outcomes for patients and delivers better value to our community. The primary health care system in WA is fragmented and lacks strong, integrated general practitioner (GP) led care at its core. WAPHA is committed to addressing the many access barriers that exist for people trying to navigate the current system particularly those at risk of poor health outcomes. These barriers contribute to more than 62,000 Western Australians presenting at hospital emergency departments each year, whose care would be best managed through a co-ordinated and responsive primary health care system. WAPHA is committed to enabling patients to stay well in the community. In the 24 months of this Activity Work Plan, the PHN intends to demonstrate improvement in equity, efficiency and effectiveness of primary health care services and in better enabling patients to stay well in the community. The founding principles of this plan include: Transitioning from a programmatic based approach to supporting Comprehensive Primary Care where General Practitioners lead, and are central to the care team/model; Comprehensive Primary care is underpinned by the 10 building blocks of high performing primary care and the Quadruple aim; Reducing fragmented care by supporting the provision of person-centred, integrated and coordinated care for vulnerable and disadvantaged people in identified geographic hot spot locations; and Place based health approach to commissioning whereby local activities are implemented to engage the community, social and health care providers, local government and other key stakeholders to knit together services to more effectively meets the needs of local citizens. Our commissioning effort and resources are focussed on a small number of high impact activities that can demonstrate our success in facilitating changes to the health system. These changes will have improved health outcomes, deliver better value to the community and will meet one or more of the following five priority areas, identified through the Needs Assessments: Keeping people well in the community; People with multiple morbidities especially chronic co-occurring physical conditions, mental health conditions and drug and alcohol treatment needs; Services designed to meet the health needs of vulnerable and disadvantaged people, including those of Aboriginal heritage; System navigation and integration to help people get the right services at the right time and in the right place; and/or Capable workforce tailored to these priorities. It will be essential that WAPHA and the PHN builds sustainable relationships across the health and social care systems that most effectively address the barriers impacting on the health care outcomes of people in metropolitan, regional, rural and remote Western Australia. Based on the services gaps and the priorities identified in the WA Primary Health Network Needs Assessments, WAPHA will plan and commission for quality, cost effective and integrated services that are sustainable, evidence based and outcomes based. Engagement of clinicians and the community in the planning and commissioning of services will assist in identifying, and subsequently meeting, priority needs at regional level for the WA community. The following will be key to the achievement of WAPHA s objectives: Establishing a sustainable commissioning capability; Increasing the system s capacity to support patients through non-hospital primary health care pathways; Fostering the authorising environment, and Building an organisational culture that supports innovation, good governance and sustainability. 4

Table of Contents Definitions applied... Error! Bookmark not defined. Key projects underpinning proposed activities... 7 Commissioning approach....8 NP 1 Comprehensive Primary Care Program (CPC) (new)... 9 NP 2 - Chronic disease management (existing)... 12 NP 3 - Pain management (existing)... 14 NP 5 - Regionally tailored mental health services (existing)... 16 NP6 - Allied health services to aged care clients (existing)... 18 NP7a - Primary health care for vulnerable people (existing)... 20 NP7b - Belvidere Health Centre - Iron Infusion Clinic (existing)... 20 NP 8 - Innovation and evidence (new)... 22 NP 9 Local Integrated Team Care (LITC) (new)... 25 OP 1 General practice support... 28 OP 2 - General practice support workforce capacity building... 30 OP 3 General practice support - continuous quality improvement... 31 OP 4 General practice support - CQI HealthPathways... 32 OP 5 General practice support - CQI - improve cancer screening rates 33 OP 6 - General practice support - CQI - improve immunisation rates... 34 OP 7 General practice support - digital health... 35 OP 8 Strategic direction... 36 OP 9 Commissioning... 37 OP 10 Population health planning... 38 OP 11 Stakeholder engagement... 39 OP 12 - Communication and marketing..40 After hours strategic vision..41 AH 1 - After Hours Metro South... 42 AH 2 After Hours centre continuity of care... 47 5

Definitions applied Canterbury Health System Outcomes Framework - an outcome measurement approach utilised within the Canterbury Health Network in New Zealand. The framework identifies the key outcomes sought at a population level and tracks performance using an evolving set of indicators, moving the health system away from tracking of inputs and aligning resource of the wider system to patient rather than provider outcomes. Clinical governance - the systems and processes that organisations use to audit care, train staff, obtain feedback from clients and manage clinical risk to ensure that the services provided are safe and good quality. Co-design - where service users, providers and commissioners are equal partners in the design of systems and services that affect them. Co-production - In practice, involves people who use services being consulted, included and working together from the start to the end of any things that affect them. (Often used as the operational description of how co-design is achieved, but also gets used interchangeably). Collective impact - an approach that brings a range of organisations together to focus on an agreed common change agenda that results in long-lasting benefits. CREMs clinician reported experience measures. Evidence based care - care that research has shown is effective in providing the desired result. HealthPathways - an online management tool to assist general practitioners (GPs) provide consistent conditions-specific care and referrals. Each pathway provides GP s with up to date information about local referral pathways. Multidisciplinary team - A term used to describe a variety of different health professionals working together. (Also called inter-professional or interdisciplinary team). Outcome based commissioning - planning and purchasing services based on what positive differences are made, over how they are done. This is a key concept in reforming our health services. An example would be where a government replaces a block contract to buy 2000 hip replacements a year, with a contract to deliver an agreed level of hip mobility for a group of people in a region, ensuring people are mobile and not in pain. Hip replacements might be the right answer in some cases, but probably in fewer cases than before, and most importantly that decision is directed much more by the outcomes that the patient wants. Person centred care - when decisions about the way health care is designed and delivered puts the needs and interests of the person receiving the care first. (Also called Consumer Centric Care). Place based approach - a way of addressing issues within a defined place, community or region in a systemic way. PREMs - Patient reported experience measures. Primary care - the first point of contact with health care provided in the community most commonly with a GP. Does not require and external referral at point of entry. PROMs - Patient reported outcome measures. Quadruple aim - is widely accepted as a compass to optimise health system performance. The Quadruple aim includes enhancing patient experience, improving population health, reducing costs and improving healthcare provider experience and satisfaction. 6

Secondary care - care provided by a specialist often in a clinic or hospital requiring an external referral. Shared care - care provided by a team of people in a coordinated way. An example would be arrangements between a local hospital and GP for pregnancy care where some appointments are with the GP, and some are at the hospital. Stepped care - A key concept in mental health. In this model the care is stepped up or down in intensity and scope, depending on the severity and complexity of the patient s needs, rather than care dosing according to diagnosis and service specification. For example, someone suffering depression related to a specific incident in their life such as sickness or job loss, will require a different level of care to a person with long-term chronic depression or psychiatric conditions. With a stepped care approach, all patients with depression start with low intensity intervention, usually watchful waiting, as around half will recover spontaneously within 3 months. Progress is monitored by a mental health professional and only those who don t recover sufficiently move up to higher intensity intervention which might involve guided self-help. There are two more levels or steps: brief one-on-one therapy; and then for those still badly impacted by depression, longer-term psychotherapy and antidepressant medication. Systems approach - a way of tackling issues by looking at all the services that exist and the connections between them and making changes that can affect the whole system rather than just individual parts within it. Social determinants of health - the conditions within which people are born, develop, grow and age they include social, economic, cultural and material factors surrounding people's lives, such as housing, education, availability of nutritional food, employment, social support, health care systems and secure early life. Tertiary care - specialised care usually provided in hospital that usually requires referral from a primary or secondary care provider. Wrap around care - this is a key concept within person centred care. The patient and their family form a partnership with their primary care provider team and other services wrap around this partnership as required. Key Projects underpinning proposed activities Mental Health Atlas project -The project maps by primary function, all of the free to access mental health and AOD services in WA including their reach. Once completed (due September 2016) the project will provide a planning tool that helps health commissioning organisations to understand current service availability by locality. My Health Record project - My Health Record is a secure online summary of a person s health information, provided to all Australians by the Commonwealth Department of Health. The individual can control what goes into the record and who can access it. The My Health Record makes it possible for an individual to share their health information with a variety of healthcare services and providers such as GP s, hospitals and specialists. Everyone granted access to the record is able to see information about an individual s health condition, allergies, test results or medications depending on what the individual elects to share, and with whom. The benefits are significant the electronic record is a convenient way for people to store all of their health information and also in reducing duplication and potential errors through health professionals having access to the right information all in one place. 7

A note on the PHN s commissioning approach and performance management To facilitate and support the move from programme funding to outcome based commissioning the WA PHNs, supported by WAPHA and in collaboration with the community, providers and other stakeholders, will develop a State-wide primary care outcomes framework ( the framework ). This framework will include a suite of indicators (process, output and outcome). It will also be available for use by other stakeholders in the primary care sector. Wherever possible, it will draw on and align with existing work at a national and State level (for example, the National Primary Health Care Strategic Framework, WA Department of Health s Aboriginal Health and Wellbeing Framework 2015-2030, and the Partnering in Procurement Guidelines produced by the WA Council of Social Services and the WA Department of Health). In line with the Department of Health s guidance documents on designing and contracting services the framework will be developed with the following principles: Indicators will be developed in collaboration with the community, providers and other stakeholders; Duplication in data collection and reporting for providers will be minimised wherever possible for example, by collaborating with other funders to agree shared performance measures; Timely and responsive feedback on performance will be provided to service providers; Measurement will be at patient-level (de-identified) wherever possible; Providers will be supported to develop their capacity to identify and report appropriate outcomes and indicators; and Annual changes to local indicators will be minimised. It is intended to complete a first iteration of this work by the end of October 2016. Approach taken to prioritising activities During 2016, Perth North PHN undertook a baseline needs assessment of its resident population in partnership with Curtin University. While a broad range of health needs were identified within the community, key stakeholders were involved in a prioritisation process to agree high level priority needs. The following needs were determined: Keeping people well in the community; People with multiple morbidities especially chronic co-occurring physical conditions, mental health conditions and drug and alcohol treatment needs; Services designed to meet the health needs of vulnerable and disadvantaged people, including those of Aboriginal heritage; System navigation and integration to help people get the right services, at the right time and in the right place; and/or Capable workforce tailored to these priorities. These priority needs will guide resource allocation in the commissioning process. 8

1 (b) Planned activities funded by the flexible funding stream under the Schedule Primary Health Networks Core Funding Proposed Activities Priority Area (eg. 1, 2, 3) Activity Title / Reference (eg. NP 1.1) 1. Keeping people well in the community. 2. People with multiple morbidities especially chronic co-occurring physical conditions, mental health conditions and drug and alcohol treatment needs. 3. Services designed to meet the health needs of vulnerable and disadvantaged people, including those of Aboriginal heritage. 4. System navigation and integration to help people get the right services, at the right time and in the right place. 5. Capable workforce tailored to these priorities. NP 1 Comprehensive Primary Care Program (CPC) (new) The Comprehensive Primary Care program will implement transformational strategies that can be embedded by general practices, in identified geographical hot spot locations, where residents have a high proportion of cooccurring chronic, long term conditions. Interested practices will be provided with assistance by the PHN to understand and implement (iteratively) the requisite changes in practice structure and function to transition to a Comprehensive Primary Care program. Enrolled patient cohorts will be from the rising-risk chronic disease population group who are not yet sick enough for expensive tertiary care but will benefit from good clinical control and patient management of disease to decrease the burden and complications of disease. Description of Activity The PHN will support participating practices in the following ways: Investing in knowledge and GP leadership of Comprehensive Primary Care principles and best practice; Implementation of the 10 Building Blocks of High Performing Primary Care across selected practices; a practice support and improvement process; Measuring the impact on quality metrics and development of practice dashboards; Strengthening a primary care foundation for integrated care; Strengthening collegiality and change readiness among GPs, Allied Health Providers, Area Health Services and internally; and Building general practice capacity in team care arrangements including self-management and other support for identified patients. Patient and clinician feedback and outcomes will be measured throughout the program and changes will be made to improve the model throughout the duration. 9

Proposed Activities Collaboration Indigenous Specific GP and Education training bodies, Private Health Insurers, professional colleges, universities, other WA PHN s, GP s in the PHN and Patients their families and carers. No. Duration October 2016 June 2018. Coverage Perth South PHN has targeted specific geographic areas in line with the PHN needs assessment process. Detailed below are the priority areas of need (in alphabetical order). Others may be identified through the EOI process. Armadale (SA3); Belmont Ascot Redcliffe (SA2); Canning (SA3) Cockburn (SA3); Fremantle (SA3); Gosnells (SA2); Kwinana (SA3); Mandurah (SA3); Murray (SA2); Rockingham (SA3); Serpentine - Jarrahdale (SA3); Victoria Park Lathlain Burswood (SA2); and Waroona (SA2). Commissioning approach These specific areas have been prioritised to ensure funded activities and services are being provided in areas of greatest need. However, the EOI will be open across the PHN to enable participation from practices that demonstrate innovation and capacity to test the Comprehensive Primary Care principles and to practices that identify themselves as focussing on the health needs of vulnerable and disadvantaged people, including Aboriginal people 1. Expressions of interest (EOI) will be sought from across the PHN region, with priority focus locations identified from the needs assessment. The EOI will provide detail of key elements of the Comprehensive Primary Care construct, parameters and options within which a general practice can run a Comprehensive Primary Care program. 1 PHN Needs Assessment, Priority 3: Services designed to meet the health of vulnerable and disadvantaged people including those of Aboriginal heritage, b. Commission models of primary health care that incorporate cultural proficiency and align with evidence based policy frameworks for working with Aboriginal people and other disadvantaged people. 10

Proposed Activities Shortlisted respondents from the EOI process will be engaged on a 1:1 basis to co-create the details of contracts. Appropriate measures and indicators (including PREMs and PROMs) will be agreed in partnership with GP practices and their associated allied health providers and/or practice networks. Commissioning approach Six monthly reporting is expected to include identification of the barriers and enablers to delivery of the Comprehensive Primary Care program. Third party evaluation of the program as a whole will be conducted by a research partner, providing an evidence base to inform future scaling and implementation. Performance indicators will be negotiated with providers and other stakeholders in line with the WA Primary Care Outcomes Framework. Performance Indicator Local Performance Indicator target Data source Planned Expenditure 2016-2017 (GST exc) to match budget Indicators are expected to include: Process My Health Records activity; Immunisation rates; MBS activity related to PPHs; Health Pathways activity; PREMS; and CREMS. Output Identification of at risk population; and Enrolment of at risk population. Outcome Increased planned care and decreased acute care; Decreased wait times; and PROMs. During the commissioning phase (July 2016 March 2017), the PHN will work with stakeholders and providers to agree local targets in line with the state-wide outcomes framework. To be agreed. Potential sources include provider patient-level (de-identified) data; state-wide data sets; national data sets. $1,000,000 Flexible funding $0 Funding from other sources (e.g. private organisations, state and territory governments) 11

Proposed Activities Priority Area (eg. 1, 2, 3) Activity Title / Reference (eg. NP 1.1) Description of Activity Collaboration 1. Keeping people well in the community. 2. People with multiple morbidities especially chronic co-occurring physical conditions, mental health conditions and drug and alcohol treatment needs. 3. Services designed to meet the health needs of vulnerable and disadvantaged people, including those of Aboriginal heritage. 4. System navigation and integration to help people get the right services, at the right time and in the right place. NP 2 - Chronic disease management (existing) Active Measures is a free community based weight loss program available to participants with a Body Mass Index (BMI) over 30. The program runs for a twelve-month period during which participants have access to a Dietitian and an exercise program run by an accredited exercise physiologist 2. This multidisciplinary intervention gives clients ongoing support to help achieve weight loss and healthy lifestyle goals. If patients demonstrate the need for psychological support they are directed to Arche s in-house In Focus counselling program 3. The HeartBeat Community Cardiac Care Program is a seven-week group education and exercise program. Each week participants meet for 2 hours where they receive one hour of education provided by a multidisciplinary team of allied health professionals followed by one hour of supervised exercise conducted by an accredited exercise physiologist. The exercise is a supervised, progressive program that is a combination of cardiovascular exercises, resistance training and balance and coordination exercises 4. Regionally Tailored Chronic Condition Services (RT-CD) Target group: People with existing chronic conditions or at high risk of chronic conditions 5. Allied health professionals including a dietitian, exercise physiologist and diabetes educator deliver group and individual services for those referred with chronic conditions. These services are stand-alone and available via direct referral for conditions including, but not limited to, diabetes, cardiovascular disease, early renal disease and musculoskeletal problems. In addition to direct service delivery, allied health professionals contribute to program development, development of referral pathways, coordination of complex patient care, and integration of services across the region and shared care arrangements with tertiary services. Care coordination underpins the effectiveness of the service delivered. Care coordination underpins the effectiveness of the service delivered by the health professionals 6 The programs listed within this plan are solely funded by Perth South PHN. 2 PHN Needs Assessment, priority 1: Keeping people well in the community, b. Commission strategies to keep people connected to their GP or General Practice 3 PHN Needs Assessment, priority 2: People with multiple morbidities especially chronic co-occurring physical conditions and mental health conditions, a. Commission models of integrated complex chronic care management incorporating proactive coordination and multi-disciplinary collaboration 4 PHN Needs Assessment, priority 1: Keeping people well in the community, b. Commission strategies to keep people connected to their GP or General Practice 5 PHN Needs Assessment, priority 1: Keeping people well in the community, b. Commission strategies to keep people connected to their GP or General Practice 6 PHN Needs Assessment, priority 4: System navigation and integration to help people get the right services at the right time and in the right place, a. Work in partnership with GPs, state and area health services on Health Pathways to help increase GPs use of approved referral pathways and processes, navigate the system and provide effective and timely diagnoses and referral 12

Proposed Activities Indigenous Specific All 3 programs work closely with local Care Coordination Supplementary Services delivering culturally appropriate services to Aboriginal people in need 7. Duration July 2016 March 2017. Coverage Each program receives referrals from throughout Perth South PHN region. Perth South East (SA4) Perth South West (SA4) Chronic disease management services were identified in the Perth South PHN Baseline Needs Assessment as an option within several priority areas across the region. Commissioning approach The contract for these services will be extended with Arche health and 360 Health and Community until 30/03/17. From 2017 it is anticipated that the Comprehensive Primary Care program and Local Integrated Team Care (LITC) will be underway and targeting vulnerable clients in identified geographical hot spot locations where residents have a high proportion of co-occurring chronic, long term conditions (see NP 1 and NP 9). Performance indicators for the 9 month contract extension will remain as currently contracted. Additional process or outcome indicators such as Patient Reported Experience Measures or Patient Reported Outcome Measures to be negotiated. Performance Indicator Local Performance Indicator target Data source Planned Expenditure 2016-2017 (GST exc) to match budget During this time, we will work in partnership with providers and other stakeholders to identify and agree future local performance indicators. During the commissioning phase (July 2016 March 2017), the PHN will work with stakeholders and providers to agree process, output and outcome indicators for Local Integrated Team Care based on the state-wide outcomes framework. Local performance indicator targets for the 9 month contract extension to be negotiated. To be agreed. Potential sources include provider patient-level (de-identified) data; state-wide data sets; national data sets. $ 631,174 Commonwealth funding $0 Funding from other sources (e.g. private organisations, state and territory governments) 7 PHN Needs Assessment, Priority 3: Services designed to meet the health of vulnerable and disadvantaged people including those of Aboriginal heritage. 13

Proposed Activities Priority Area (eg. 1, 2, 3) Activity Title / Reference (eg. NP 1.1) Description of Activity 1. Keeping people well in the community. 2. People with multiple morbidities especially chronic co-occurring physical conditions, mental health conditions and drug and alcohol treatment needs. 3. System navigation and integration to help people get the right services, at the right time and in the right place. NP 3 - Pain management (existing) The STEPS (Self Training Educative Pain Sessions) program is a high quality pain management program targeted at individuals living with chronic pain 8. Clients attend a series of group education sessions over two days, followed by 1:1 visits with each member of the multidisciplinary team: behavioural medicine specialist, a physiotherapist and a pain specialist 9. Care coordination to other programs is a key component of this program for ongoing management and support. Collaboration Indigenous Specific Data is analysed to monitor health outcomes of participants and for continuous quality improvement activities. This early identification and treatment at a primary care level is designed to facilitate reduced reliance on tertiary services in the future 10. The programs listed within this plan are solely funded by Perth South PHN. No. Duration July 1 2016 March 31 2017. Coverage Each program receives referrals from throughout Perth South PHN region. Perth South East (SA4) Perth South West (SA4) The contracts for this service will be extended with Arche Health and 360 Health and community until 30/03/17. Commissioning approach From 2017 it is anticipated that the Comprehensive Primary Care program and Local Integrated Team Care (LITC) will be underway and targeting vulnerable clients in identified geographical hot spot locations where residents have a high proportion of co-occurring chronic, long term conditions (see NP 1 and NP 9). 8 PHN Needs Assessment, priority 1: Keeping people well in the community, b. Commission strategies to keep people connected to their GP or General Practice 9 PHN Needs Assessment, priority 2: People with multiple morbidities especially chronic co-occurring physical conditions and mental health conditions, a. Commission models of integrated complex chronic care management incorporating proactive coordination and multi-disciplinary collaboration 10 PHN Needs Assessment, priority 4: System navigation and integration to help people get the right services at the right time and in the right place, a. Work in partnership with GPs, state and area health services on Health Pathways to help increase GPs use of approved referral pathways and processes, navigate the system and provide effective and timely diagnoses and referral 14

Proposed Activities Priority Area (eg. 1, 2, 3) Activity Title / Reference (eg. NP 1.1) Description of Activity 1. Keeping people well in the community. 2. People with multiple morbidities especially chronic co-occurring physical conditions, mental health conditions and drug and alcohol treatment needs. 3. Services designed to meet the health needs of vulnerable and disadvantaged people, including those of Aboriginal heritage. 4. System navigation and integration to help people get the right services, at the right time and in the right place. NP 5 - Regionally tailored mental health services (existing) This service provides evidence based short term counselling and care coordination to individuals with a broad range of mild to moderate mental health concerns 11. Activities include group and individual education/information, clinical intervention and liaison and shared triage with the State Adult Mental Health Service 12. Collaboration Duration July 2016 March 2017. Coverage Care coordination is an important aspect of this service ensuring each referred client is able to access a suitable service 13. This service will be linked to the State Adult Mental Health Service and a shared care model exists and will be utilised including triage 14. PHN Perth South region, focussing on the Peel region. Perth South East SA4 Perth South West SA4 Mandurah SA2 Pinjarra SA2 11 PHN Needs Assessment, priority 2: People with multiple morbidities especially chronic co-occurring physical conditions and mental health conditions, a. Commission models of integrated complex chronic care management incorporating proactive coordination and multi-disciplinary collaboration 12 PHN Needs Assessment, priority 3 Services designed to meet the health of vulnerable and disadvantaged people including those of Aboriginal heritage, f. Develop strategies and partnerships to achieve targeted cocommissioning and integrated delivery plans with key service providers. 13 PHN Needs Assessment, priority 2: People with multiple morbidities especially chronic co-occurring physical conditions and mental health conditions, c. Commission and implement strategies to ensure chronic condition self-management principles are included in care plans 14 PHN Needs Assessment, priority 1: Keeping people well in the community, a. Work in partnerships with State and Area Health Services, hospitals and General Practitioners (GPs) to effectively manage the hospitalcommunity interface. 16

Proposed Activities Commissioning approach Performance Indicator Local Performance Indicator target Data source Planned Expenditure 2016-2017 (GST exc) The contract for this service provided by 360 health and Community will be extended until 30/03/17. From 2017 it is anticipated that activities covered by this Service will be incorporated into and delivered under activities outlined in the PHN Mental Health Plan. Performance indicators for the 9 month contract extension will remain as currently contracted. Additional process or outcome indicators such as Patient Reported Experience Measures or Patient Reported Outcome Measures to be negotiated. During this time, we will work in partnership with providers and other stakeholders to identify and agree future local performance indicators. During the commissioning phase (July 2016 March 2017), the PHN will work with stakeholders and providers to agree process, output and outcome indicators for Local Integrated Team Care based on the state-wide outcomes framework. Local performance indicator targets for the 9 month contract extension to be negotiated. To be agreed. Potential sources include provider patient-level (de-identified) data; state-wide data sets; national data sets. $270,000 Commonwealth funding $0 Funding from other sources (eg. private organisations, state and territory governments) 17

Proposed Activities Priority Area (eg. 1, 2, 3) Activity Title / Reference (eg. NP 1.1) Description of Activity 1. People with multiple morbidities especially chronic co-occurring physical conditions, mental health conditions and drug and alcohol treatment needs. 2. Services designed to meet the health needs of vulnerable and disadvantaged people, including those of Aboriginal heritage. 3. System navigation and integration to help people get the right services, at the right time and in the right place. 4. Capable workforce tailored to these priorities. NP6 Allied health services to aged care clients (existing) These activities will be continued by the incumbent service provider Arche Health until March 2017. 1. Allied health services Social worker services that are not covered by Medicare or other government funding will be provided to residents of residential aged care facilities with multiple morbidities. Services will also include engagement with Aboriginal clients and carers in RACFs to ensure delivery of accessible services. Collaboration Indigenous Specific 2. Education workshops Educational workshops will be delivered that support the clinical competence of RACF staff in preventing inappropriate hospital admissions. Arche Health collaborates with RACF s assessment teams and services, allied health clinicians and the Residential care Line and 360 Health and Community as partners in delivering educational workshops. No. Duration July 2016 March 2017. Coverage Commissioning approach The geographic coverage for the activity is predominantly Perth South East (SA4), however in response to service gaps some services have historically been delivered in Perth South West (SA4). There is currently some duplication of activity with the provider of this activity (Arche Health) and the Better Health Care Connections Program (360 Health & Community). The PHN will work collectively with the providers to reduce duplication and improve collaboration to meet the health needs for their respective target groups. The contract for these services will be extended with Arche health until 30/03/17. 18

Proposed Activities Performance Indicator Local Performance Indicator target Data source Planned Expenditure 2016-2017 (GST exc) Performance indicators for the 9 month contract extension will remain as currently contracted. However the PHN will also negotiate with service providers to report on additional process or outcome indicators such as Patient Reported Experience Measures or Patient Reported Outcome Measures where possible. It is therefore anticipated that the performance indicators could include, but would not be limited to: Output Number of people who receive the allied health care service; Number and types of allied health episodes of service (disaggregated between RACF and community and type of service); Client demographics; Number and location of RACFs where allied health services have been delivered; Percentage of RACFs visited per SA4 area; and Number, profile and location of education workshops delivered including the number of workshop attendees. Process Clinician Reported Experience Measure (CREMs); Patient Reported Experience Measure (PROMs); and Cost per occasion of service. Outcome Patient Reported Outcome Measures; and Clinician Reported Outcome Measures. As outlined above, the PHN will work in partnership with providers to establish baselines and agree targets for local performance indicators before June 2016. To be confirmed. It is anticipated that data will be drawn from provider patient records (de-identified). $233,619 Commonwealth funding $0 Funding from other sources (e.g. private organisations, state and territory governments) 19

Proposed Activities Priority Area (eg. 1, 2, 3) Activity Title / Reference (eg. NP 1.1) Description of Activity Collaboration 1. Keeping people well in the community 2. Services designed to meet the health needs of vulnerable and disadvantaged people, including those of Aboriginal heritage. 3. System navigation and integration to help people get the right services, at the right time and in the right place. NP7a - Primary health care for vulnerable people (existing) NP7b - Belvidere Health Centre - Iron Infusion Clinic (existing) Activity description - Primary health care for vulnerable people (NP7a) Provides accessible tailored primary health care to people of Aboriginal and CaLD heritage, people of Low Socioeconomic Status (SES) and elderly people living in the community through care co-ordination, assistance with appointments and transport and implementing team care arrangements for vulnerable people requiring ongoing care. Activity description (NP7b) Belvidere Health Centre Iron Infusion Clinic (Clinic) The clinic provides community-based intravenous management of iron deficiency (ID) focusing the service on pre-operative, chronic disease and elderly patients on GP referral. The program s service model is reliant on integration and alignment of a range of services including GP s and allied health, Aboriginal Health Organisations, NGO s, Hospitals, LGA s and University (research partner). Indigenous Specific No. Duration July 2016 March 2017. Coverage Commissioning approach Each program receives referrals from throughout Perth South PHN region. Perth South East (SA4) Perth South West (SA4) The contract for these services will be extended with Arche health until 30/03/17. From 2017, it is anticipated that the Comprehensive Primary Care programs and Local Integrated Team Care (LITC) will be underway and targeting vulnerable clients in identified geographical hot spot locations where residents have a high proportion of co-occurring chronic, long term conditions (see NP 1 and NP 9). This service may be eligible to participate in the Comprehensive Primary Care programs (See NP 1), following completion of the current contract term. 20

Proposed Activities Performance Indicator Local Performance Indicator target Data source Planned Expenditure 2016-2017 (GST exc) to match budget Performance indicators for the 9 month contract extension will remain as currently contracted. Additional process or outcome indicators such as Patient Reported Experience Measures or Patient Reported Outcome Measures to be negotiated. During this time, we will work in partnership with the provider and other stakeholders to identify and agree future local performance indicators. During the commissioning phase (July 2016 March 2017), the PHN will work with stakeholders and providers to agree process, output and outcome indicators for Local Integrated Team Care based on the state-wide outcomes framework. Local performance indicator targets for the 9 month contract extension to be negotiated. To be agreed. Potential sources include provider patient-level (de-identified) data; state-wide data sets; national data sets. $116,502 Commonwealth funding $0 Funding from other sources (e.g. private organisations, state and territory governments) 21

Proposed Activities Priority Area (eg. 1, 2, 3) Activity Title / Reference (eg. NP 1.1) 1. Keeping people well in the community. 2. People with multiple morbidities especially chronic co-occurring physical conditions, mental health conditions and drug and alcohol treatment needs. 3. Services designed to meet the health needs of vulnerable and disadvantaged people, including those of Aboriginal heritage. 4. System navigation and integration to help people get the right services, at the right time and in the right place. 5. Capable workforce tailored to these priorities. NP 8 Innovation and evidence (new) This project will provide the PHN with the flexibility to respond to locally identified opportunities for innovation in line with PHN priorities. The budget will be allocated to one-off projects that demonstrate evidence of working across health and social care systems and organisations to improve the delivery of primary care and an ability to be implemented or sustained beyond the 12 month funding period. A provider will not receive more than one allocation from this fund in any one year. Projects will be no longer than 12 months. Description of Activity For example a grant could be used develop improved models of care and test innovative local collaborative models with a focus on chronic disease factors. The service providers will establish place based systems of care in which they work together with the common resources available to improve health and social care for the population they serve within identified hotspots. A further role of the PHN will be to facilitate collaborations between organisations and individuals to test models and share knowledge and learning s. An allocation of this budget will be used to undertake ongoing improvement and evaluation of the Comprehensive Primary Care initiative. Projects will be selected according to a transparent process and criteria, including: Alignment with PHN priorities; Project governance; Capacity/capability of provider to deliver the project within the agreed timeframe; Innovation; 22

Proposed Activities Description of Activity How well can the innovation be expanded and translated into other environments; Impact; Rationale; Evaluation; and Stakeholder engagement. Risk Collaboration Indigenous Specific Duration Coverage Commissioning approach Performance Indicator Desirable - Availability of additional or matched funds (i.e. PHN funding will unlock additional funding from another organisation). It is anticipated that some projects will be jointly implemented with stakeholders including Local Health Networks and State Government. No. Throughout the financial year. Projects will last up to 12 months. Each program receives referrals from throughout Perth South PHN region. Perth South East (SA4) Perth South West (SA4) Projects which address the PHN priorities will be proactively identified by PHN staff and reviewed regularly by PHN management with input from the Community Engagement Committee and the Clinical Commissioning Committee. Recommendations will be made to PHN Council and Board for approval as opportunities are identified. It is anticipated that funding will be allocated via direct engagement. Provider indicators: local performance indicators will be agreed with providers in line with project objectives. Potential indicators include: Process measures: - Volume (clients, partners, episodes, visits, stakeholder meetings); and - Project objectives achieved (yes/no/partial). Output measures examples: - Project scope written; - Information produced (i.e. leaflets/brochures for clients/users/consumers etc); and - Relevant data gathered (i.e. was the desired data achieved? E.g. feedback from consumers, functional improvements etc). Outcome measures: - Feedback from clients/consumers/patients/ stakeholders (i.e. content of the data what did it tell us?); and - Relevant measures tailored to the project (i.e. PROMs, PREMs, improvement in a particular measure etc). 23