Southern Melbourne Primary Care Partnership Service Coordination and Integrated Chronic Disease Management Operational Plan

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1 Suthern Melburne Primary Care Partnership Service Crdinatin and Integrated Chrnic Disease Management Operatinal Plan The fllwing agencies are partners t and participants in the Suthern Melburne Primary Care (SMPCP) Operatinal plan as at July Access Care Suthern City f Prt Phillip Alfred Health City f Stnningtn Bayside City Cuncil Inner Suth Cmmunity Health Service Bentleigh Bayside Cmmunity Health Cmmnwealth Respite and Carelink Centre Suthern Regin Bethlehem Mnash Health Cabrini Hspital Kingstn ACAS Caulfield ACAS Ryal District Nursing Service Central Bayside Cmmunity Health Services Suthern Melburne Primary Care Partnership (SMPCP) City f Kingstn SMPCP Cmmunity Cnsumer Cllabratin Grup SMPCP Strategic Plan Pririty Areas: Access t an Integrated Service System (Objectives 1 and 2) : Mental Health (Objective 3) Overall Objective T strengthen the primary health system t deliver persn centred and accessible early interventin and integrated care that aims t keep peple as well as pssible fr as lng as pssible particularly peple with cmplex needs Objective 1 Wrk with member rganisatins and Medicare Lcals* t strengthen integratin and cmmunicatin practices amng prviders (including between state-funded and private prviders) t facilitate cnsumer transitins between services and reduce the need fr cnsumers t relive their experiences Facilitate the advancement f Victrian Service Crdinatin Practice Manual 2012 implementatin t brader health and wellbeing agencies (adapted frm DH Prgram Lgic) Strategies Activities Timelines Perfrmance Strategy 1.1 Supprt agencies t implement and adhere t agreed Sharing f Client Infrmatin practice as utlined in the SMPCP Statement f Cmmitment (SOC) including assisting partner agencies t implement and sustain an e cmmunicatin system that delivers the SOC principles and practice ** Establish an Infrmatin Sharing and e-cmmunicatin wrk grup t: Establish a base line f current infrmatin sharing between agencies (what is the current agency cmpliance with SOC principles?) Review current encrypted infrmatin sharing status acrss partnership agencies: establish a baseline f usage and platfrms (which system and wh is using it?) By December 2015 Measures/Indicatrs Baseline f current infrmatin sharing is dcumented and prvided t the Service Crdinatin and Integrated Care Steering Cmmittee (SCIC) Estimated Impact/Shrt Term Outcmes Agreed implementatin plan fr e-cmmunicatin and/r encryptin systems t enable infrmatin sharing cmpliant with SOC principles 1

2 Suthern Melburne Primary Care Partnership Service Crdinatin and Integrated Chrnic Disease Management Operatinal Plan Establish criteria fr evaluating current encryptin systems t frame recmmendatins (e.g. % using, cst f implementatin, capability fr supprting SOC principles and reprting and auditing capability including service prvider uptake and SOC principle cmpliance) Evaluate systems and recmmend preferred e- cmmunicatin system including resurces required t implement the system SCIC Steering Cmmittee t wrk with partner Agencies t determine feasibility f implementing recmmendatins By April 2016 Current e- cmmunicatin baseline (platfrms and usage) dcumented and prvided t the SCIC Recmmendatins fr preferred e- cmmunicatin system and resurces required t implement prvided t the SCIC Implementatin f plan Strategy 1.2 Supprt agencies t evaluate use f and adherence t SOC, and e-cmmunicatin use Wrk with partner agencies t implement the recmmendatins re e-cmmunicatin/ encryptin as per agreed implementatin plan Educate agencies regarding the SOC and Sharing f Client Infrmatin practice Encurage agencies t incrprate expectatins regarding practice in agency prcesses e.g. inductin, staff develpment and business plans Develp an evaluatin methd Cnduct evaluatin Implementatin plan develped By June 2017 Implementatin plan cmpleted Evaluatin measures may include: - N f agencies aware f SOC and Sharing f infrmatin practice - N f agencies with SOC in prcesses and plans - N f staff infrmed f requirement t practice in accrdance with SOC - Evidence f increased cmpliance with SOC Increased infrmatin sharing cmpliant with SOC principles, resulting in less duplicatin f assessments and better crdinatin f care (mre efficient fr clients and wrkers). 2

3 Suthern Melburne Primary Care Partnership Service Crdinatin and Integrated Chrnic Disease Management Operatinal Plan principles f infrmatin sharing (frm baseline) - N f e-referrals/care plans Strategy 1.3 Engage ISCH t pilt the SCTT Cnsumer Administered Single page screener frm n behalf f member agencies t gauge the Screener s impact in identifying risk factrs fr chrnic cnditins/issues (e.g. Family Vilence), t determine its implementatin impact n agencies and client care and t develp recmmendatins and resurces fr agency adptin ISCH t: Develp wrk instructins fr the pilt f the SCTT Develp an electrnic package f training and resurces t supprt staff acrss agencies t implement risk factr screening and respnse Deliver training Pilt the use f the SCTT ver a 4 week perid Evaluate the SCTT against the prject aims Cmplete a reprt including evaluatin utcmes, cnsideratins and recmmendatins fr implementatin f the Cnsumer Administered SCTT Prvide recrded training and electrnic resurces fr prvisin t SMPCP member agencies. Nte this resurce wuld be applicable t supprt staff with whatever methd f risk screening an agency may implement. June Wrk instructins cmpleted Training and resurces develped Training delivered Pilt cmpleted and evaluated Recmmendatins and cnsideratins fr implementatin prvided in reprt t SCIC Recrded training and electrnic resurces made available t SMPCP member agencies. Agencies will have clear guidelines t implement the SCTT (and in what circumstances) Agencies will have the resurces they need t supprt staff t implement the SCTT Single Page Screener. Shuld the cnsumer administered SCTT prve t be a useful and efficient tl mre clients will have the pprtunity t identify risk factrs and be supprted t address them. 3

4 Strategy 1.4 Supprt the establishment f a partnership wide Special Interest Grup fr Intake Wrkers Suthern Melburne Primary Care Partnership Service Crdinatin and Integrated Chrnic Disease Management Operatinal Plan Hld a frum fr Intake wrkers t: explre existing Intake mdels establish Special Interest Grup develp Terms f Reference/pririties fr future wrk By Octber 2015 Hlding f wrkshp Grup establishment Pririty identificatin Greater understanding f intake mdels acrss the SMPCP Intake wrkers feel mre infrmed and supprted Strategy 1.5 Prvide wrkfrce develpment pprtunities in respnse t identified need/pririty e.g. in respnse t Klin-Balit findings, utcmes frm the Clinician s wrk grup and recmmendatins n the implementatin f the SCTT ne page screener Engage trainer Prvide training Evaluate training utcmes By June 2016 N f training sessins N f staff trained Increased knwledge and understanding in specified wrkfrce develpment areas Strategy 1.6 Supprt and resurce lcal partnership grups: the SRS Netwrk and HACC, ACAS Packaged Care Alliance Prvide crdinatin and administrative supprt t SRS Netwrk Prvide in kind supprt t HACC, ACAS Packaged Care Alliance Onging Meeting rganisatin Attendance at meetings Onging functining f lcal partnership grups Objective 2 Wrk with member rganisatins t identify and address barriers t the delivery f care fr chrnic illness. Strategies Activities Timelines Perfrmance Strategy 2.1 Supprt agencies t further embed and sustain best practice appraches t Chrnic Illness in Establish a Clinician s wrking grup hld wrkshp t cnfirm current situatin and establish grup Measures/Indicatrs March 2015 Hlding f wrkshps Estimated Impact/Shrt Term Outcmes Cllective apprach t imprving ICDM 4

5 Suthern Melburne Primary Care Partnership Service Crdinatin and Integrated Chrnic Disease Management Operatinal Plan accrdance with the Wagner Chrnic Care Mdel Supprt wrkgrup t determine ICDM pririties fr actin hld 2 nd wrkshp t identify pririties May 2015 Grup establishment Pririty identificatin (including pririty area) in SMPCP Greater cmmnality in appraches t ICDM Objective 3 Facilitate implementatin f lcal agreements and systematic interagency care pathways fr defined cnsumer chrts using evidence-based guidelines Strategies Activities Timelines Perfrmance Measures/Indicatrs Strategy 3.1 Cntinue t mnitr Mental Cnsider Health Matters prject utcmes Onging Mental Health Health system changes and Mental Health updates prvided and discussed at Discussin minuted prjects with a view t develping Mental Health Service Crdinatin and Integrated Care meetings prject Estimated Impact/Shrt Term Outcmes Greater understanding f mental health situatin and areas f need *Nte: Medicare Lcals ceased peratin in June Primary Health Netwrks have been in peratin since July 2015 and will be invited t participate in the SMPCP Service Crdinatin and Integrated Care plan. **Nte: Infrmatin Sharing includes: Cnsumer details, Initial Needs Identificatin, Assessment, Risk Assessment, Alerts, Care Planning and Care and Service Outcmes. 5

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