Primary Health Networks: Integrated Team Care Funding Activity Work Plan 2016-2017: Annual Plan 2016-2017 Annual Budget 2016-2017 Murrumbidgee PHN When submitting this Activity Work Plan 2016-2017 to the Department of Health, the PHN must ensure that all internal clearances have been obtained and has been endorsed by the CEO. The Activity Work Plan must be lodged to <name of Grant Officer> via email <email address> on or before 15 July 2016. 1
Introduction Overview The aims of Integrated Team Care are to: contribute to improving health outcomes for Aboriginal and Torres Strait Islander people with chronic health conditions through better access to coordinated and multidisciplinary care; and contribute to closing the gap in life expectancy by improved access to culturally appropriate mainstream primary care services (including but not limited to general practice, allied health and specialists) for Aboriginal and Torres Strait Islander people. The objectives of Integrated Team Care are to: achieve better treatment and management of chronic conditions for Aboriginal and Torres Strait Islander people, through better access to the required services and better care coordination and provision of supplementary services; foster collaboration and support between the mainstream primary care and the Aboriginal and Torres Strait Islander health sectors; improve the capacity of mainstream primary care services to deliver culturally appropriate services to Aboriginal and Torres Strait Islander people; increase the uptake of Aboriginal and Torres Strait Islander specific Medicare Benefits Schedule (MBS) items, including Health Assessments for Aboriginal and Torres Strait Islander people and follow up items; support mainstream primary care services to encourage Aboriginal and Torres Strait Islander people to self-identify; and increase awareness and understanding of measures relevant to mainstream primary care. Each PHN must make informed choices about how best to use its resources to achieve these objectives. PHNs will outline activities to meet the Integrated Team Care objectives in this document, the Activity Work Plan template. This Activity Work Plan covers the period from 1 July 2016 to 30 June 2017. To assist with PHN planning, each activity nominated in this work plan should be proposed for a period of 12 months. The Department of Health will require the submission of a new or updated Activity Work Plan for 2017-18 at a later date. The Activity Work Plan template has the following parts: 1. The Integrated Team Care Annual Plan 2016-2017 which will provide: a) The strategic vision of your PHN for achieving the ITC objectives. b) A description of planned activities funded by Integrated Team Care funding under the Indigenous Australians Health Programme (IAHP) Schedule. 2. The indicative Budget for Integrated Team Care funding for 2016-2017. Activity Planning PHNs need to ensure the activities identified in this Annual Plan correspond with the: ITC aims and objectives; Item B.3 in the Integrated Team Care Activity in the IAHP Schedule; Local priorities identified in the Needs Assessment; ITC Implementation Guidelines; and Requirement to work with the Indigenous health sector when planning and delivering the ITC Activity. 2
Annual Plan 2016-2017 Annual plans for 2016-2017 must: base decisions about the ITC service delivery, workforce needs, workforce placement and whether a direct, targeted or open approach to the market is undertaken, upon a framework that includes needs assessment, market analyses, and clinical and consumer input including through Clinical Councils and Community Advisory Committees. Decisions must be transparent, defensible, well documented and made available to the Commonwealth upon request; and articulate a set of activities that each PHN will undertake to achieve the ITC objectives. Activity Work Plan Reporting Period and Public Accessibility The Activity Work Plan will cover the period 1 July 2016 to 30 June 2017. A review of the Activity Work Plan will be undertaken in 2017 and resubmitted as required under Item F.7 of the ITC Activity in the IAHP Schedule. Once approved by the Department, the Annual Plan component must be made available by the PHN on their website as soon as practicable. Sensitive content identified by the PHN will be excluded, subject to the agreement of the Department. Sensitive content includes the budget and any other sections of the Annual Plan which each PHN must list at Section 1(b). Once the Annual Plan has been approved by the Department, the PHN is required to perform the ITC Activity in accordance with the Annual Plan. Useful information The following may assist in the preparation of your Activity Work Plan: Item B.3 of Schedule: Primary Health Networks Integrated Team Care Funding; PHN Needs Assessment; Integrated Team Care Activity Implementation Guidelines; and Improving Access to Primary Health Care for Aboriginal and Torres Strait Islander People theme in the IAHP Guidelines. Please contact your Grants Officer if you are having any difficulties completing this document. 3
1. (a) Strategic Vision for Integrated Team Care Funding The strategic vision of Murrumbidgee PHN is to achieve better health for Murrumbidgee communities. It is recognised that the Aboriginal and Torres Strait Islander population in Murrumbidgee carries a large proportion of the burden of disease, and there is a need for the PHN to work with multiple providers across the region to improve the health outcomes of this population group. The MPHN will work towards this vision by; 1. Working collaboratively with the Aboriginal Medical Services in the Murrumbidgee, who have agreed to work as a Consortium in the delivery of Integrated Team Care Services for AMS client populations. 2. Working with a suitable provider who will deliver ITC mainstream services and support mainstream providers to deliver high quality culturally appropriate services. 3. Managing and distributing the supplementary services funding, ensuring appropriate and rapid access to these funds for eligible clients. 4. Working with a broad range of stakeholders who provide health and social services to Aboriginal and Torres Strait Islander people through the Murrumbidgee Aboriginal Health Consortium. 5. Working towards seamless and integrated care, particularly through transition from primary care to acute care and back again. 6. Using commissioning levers to maximise use of integration enablers such as digital technologies, shared care planning and healthcare pathways to create efficiencies and improve effectiveness in clinical service delivery. 4
1. (b) Planned activities funded by the IAHP Schedule for Integrated Team Care Funding PHNs must use the table below to outline the activities proposed to be undertaken within the period 2016-17. These activities will be funded under the IAHP Schedule for Integrated Team Care. Public Accountability What are the sensitive components of the PHN s Annual Plan? Please list List the Annual Plan components that the PHN considers sensitive and does not wish to upload onto its website. With the exception of Budget information, the department assumes anything that is not listed here will be uploaded by the PHN onto its website, after the Activity Work Plan is approved by the department. Nil Proposed Activities Six-month transition phase MPHN will continue to deliver services with current staff from 1 July 2016 to 30 September 2016. A Request For Proposals (RFP) to deliver services from 1 October 2016 was released on 6 June 2016. Completed proposals were submitted on 8 July 2016. Anticipated start date of ITC activity Services to be delivered by the commissioned providers will commence on 1 October 2016. Will the PHN be working with other organisations and/or pooling resources for ITC? MPHN has contributed an additional $200,000.00 from Flexible Funding to support the delivery of these services. 5
MPHN has collaborated with Aboriginal Medical Services within Murrumbidgee to determine the allocation of funding between mainstream and AMS services. The release of the ITC RFP was timed to coincide with the release of the MPHN Integrated Care Coordination services RFP. This may create opportunities relating to staffing coverage and efficiencies in service delivery across the whole region. To accommodate the needs of Aboriginal people within the Murrumbidgee, funds will be allocated amongst AMS service providers working as a consortium and a single provider for mainstream services. Service delivery and commissioning arrangements Decision framework The AMS consortium approach negates the need for the AMS s to competitively apply for funding to support their patient populations and hence will be provided with a direct offer of contract for this portion of service delivery. Discussions with the AMS Consortium relating to the service models are currently suspended during the period of the RFP to maintain the integrity of this competitive process. Contracts for both mainstream and AMS services will be awarded by 1 August enabling a 2 month period for establishment and handover of current clients in the last week of September. Consultation regarding the additional funding allocation from flexible funding and division of funding between AMS service and mainstream providers occurred with the four Clinical Councils, Community Advisory Committee and the Murrumbidgee Planning and Integration Committee. Further negotiations regarding the specific allocation of funding occurred directly with the AMS Consortium. The AMS agreement to work as a consortium eliminated the need for them to apply for funding through a competitive tender process. The individual roles of the funding as prescribed by the DoH were taken into consideration during the discussions; those being: Indigenous health project officer Identified position preferred by DoH (team leader role with a focus on supporting providers to deliver culturally appropriate services, enhancing community education of CTG initiatives and promoting Aboriginal engagement with health services) Aboriginal Outreach Worker Identified position preferred by DoH (provision of non-clinical 6
Decision framework documentation Description of ITC Activity practical support) Care Coordinator (provision of care coordination and facilitate access to supplementary service funding pool) OSR reports submitted by the AMS s to DoH provided an accurate indication of service utilisation within AMS facilities. This data is extracted from the clinical software and is based on individual clients seen on a regular basis. This data was then extrapolated out in line with projected ABS population data and provided a solid and agreeable basis for the split of funding. Care coordination and IHPO activities for Lake Cargelligo have also been allocated to the AMS Consortium, in recognition of the current activities provided by Griffith Aboriginal Medical Service in this locality. Management of the Supplementary Services funding will remain the responsibility of MPHN, who will make the funding available to both the AMS Consortium and mainstream service provider as required and in line with Commonwealth guidelines. Yes, and confirmation has been provided in writing to the AMS consortium members. ITC is provided by a team/teams of Indigenous Health Project Officers (IHPOs), Aboriginal and Torres Strait Islander Outreach Workers (Outreach Workers) and Care Coordinators. The teams will work in the following ways: The IHPOs will function as team leaders within both the Consortium and the mainstream provider services. These positions will be required to participate in the Murrumbidgee Aboriginal Health Consortium to support ongoing needs assessment and planning of services, developing multi-programme approaches and cross-sector linkages. These positions are also required to work closely with the MPHN Practice Support Team and to support both Outreach Workers and Care Coordinators. Outreach Workers will be located within the three AMS s and will support and encourage Aboriginal and Torres Strait Islander people to access health services and help to ensure that services are culturally competent. They will have strong links to the community and will be identified positions. Outreach 7
Workers will provide non-clinical practical support, e.g. helping patients to travel to their medical appointments. Care Coordinators will be qualified health workers (for example, nurses, Aboriginal Health Workers) who support eligible patients to access the services they need to treat their chronic disease according to the General Practitioner (GP) care plan. Care coordination services will include the following three phases of care: Initial assessment Active Care coordination Managed exit from the program (handover) Care coordination activities as a minimum must include the following: Direct engagement with the patient and relevant carers Direct engagement and case conferencing with GPs A care plan developed by the care team, led by the client and GP Direct engagement and case conferencing with specialists where appropriate Support for clients to cease smoking Care coordination services may be delivered through direct contact via scheduled appointments at an appropriate venue. This may include; the provider s office, clients home, general practice surgery or other appropriate facility that is accessible and comfortable for the client. Alternatively, to accommodate the large geographic area; services may also be delivered via telephone or video link, however all initial assessments are to be conducted face to face. It is expected that services are well coordinated with other service providers (including social care services) and aligned with the requirements of the client s GP management plan. Where appropriate and with the permission of the client; family and carers of the client should be involved in care coordination activities and, if required, supported to access carer support services. 8
Services must be delivered in a culturally respectful way. Care coordination is considered as the deliberate organisation of patient care activities between two or more participants (including the patient) involved in a patient s care to facilitate the appropriate delivery of health care services. Cited in Schultz et al. 2013 A systematic review of the care coordination measurement landscape. BMC Health Services Research 13:119 http://www.biomedicalcentral.com/1472-6963/13/119 There are a number of essential activities or practices by which quality care coordination can be measured, including: Establishing accountability making it clear who is responsible for what in the patients care Communication including face to face meetings, telephone contact and the transformation of information between providers. Timely and accurate facilitation of information and patient care between providers Assessment of patients needs and goals including patient self-management knowledge and goals Creating a proactive plan of care jointly created and managed by the patient and/or carer Monitoring and follow up regular review of patients progress towards care and coordination goals Support for self management education and support which align with patients care plan Linking to community resources - provide information to the patient/carer on additional resources and supports available in the community and facilitate access to these resources. Ref: Care Coordination. May 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/index.html Providers of the ITC service are expected to participate in the evolving Murrumbidgee Integrated Care Strategy this is likely to include: Shared Care Planning via an electronic shared care planning platform (to be funded and provided 9
by MPHN); Streamlined referral processes and pathways to care; Participation in relevant consortiums and working parties; Active participation in emerging models of care- including the person centred healthcare home; Uptake and use of information and communication technologies (including tele-health services and home monitoring devices); Provision of client and service level data for ongoing data analytics and service planning. ITC Workforce Aboriginal Outreach Worker positions: 2 FTE - allocated to AMS consortium Indigenous Health Project Officer Positions: 1.5 FTE in total (1 FTE mainstream provider, 0.5 FTE AMS Consortium) Care Coordination positions, (remaining funding is to be allocated as follows): 38.6% to the AMS consortium and 61.4% to mainstream service provider. It is expected that finale Care Coordination FTE will be negotiated with the successful provider and the AMS consortium following the competitive RFP process and during the contract negotiation phase. *AMS refers to Indigenous Health Services and Aboriginal Community Controlled Health Services 10
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