Barwon Medicare Local Annual Plan

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1 Barwon Medicare Local Annual Plan Strategic Directions All Barwon Medicare Local activities are underpinned by our organisational vision of well connected health systems in our community. Barwon Medicare Local s Strategic Plan aligns with the strategic objectives defined by the Department of Health, Medicare Local Operational Guidelines and as listed in Schedule All activities in presented in this plan support our organisational vision, Medicare Local strategic objectives and build on the work we have undertaken in past years to improve patient outcomes and enhance the patient journey. We have conducted a robust Comprehensive Needs Assessment (CNA) process with key stakeholders and community over the past six months to inform the specific areas outlined in the plan. This process has identified some new areas for focus but supports the service gaps and local needs identified through past health needs assessment. The Barwon Medicare Local Annual Plan incorporates a range of activities including: Collaboration and partnership with LHNs Integrating and connecting care for primary, secondary and tertiary providers both public and private Provision of nursing and allied health services where service gaps have been identified Facilitating increased access to after-hours services Supporting primary care providers to adopt best practice, quality and safety models in order to enhance patient outcomes Barwon Medicare Local has the expertise, experience and stakeholder relationships essential to delivering this plan as we continue to adapt and work within current federal government health policy reform.

2 Strategic Objective 1 Improving the patient journey through developing integrated and coordinated services Strategic Objective 2 Provide support to clinicians and service providers to improve patient care Strategic Objective 3 Identification of the health needs of local areas and development of locally focussed and responsive services 1.1 Ongoing engagement with LHNs which address communication, joint service planning and service integration and coordination. 1.2 Ongoing maintenance of current Barwon Medicare local health services directories and expansion of the docgeelong website to include information on General Practice, Dental and Pharmacy services and their realtime capacity to see patients for both the in-hours and after-hours periods. 2.1 Facilitate access to continuing professional development for GPs, Practice Nurses, Allied Health and other Primary Care staff which is based on local needs, promotes best practice, quality and safety and a multidisciplinary approach. 2.2 Provide support to GPs, Practice Nurses and Allied Health to develop and implement collaborative models of care with a focus on chronic disease management and preventive health. 2.3 Undertake a review of Cancer Multidisciplinary Team meetings in collaboration with BSWRICS which focuses on the development of a sustainable model and broader GP engagement model. 2.4 To provide GPs, Practice Nurses and Allied Health with resources and information that supports prevention and early detection of chronic disease and risk behaviours. 3.1 Ongoing collection and analysis of population health and health service mapping to identify local need, inform decision making and support the CNA process. 3.2 Collection and analysis of PENCAT data from General Practice to identify local health needs and inform decision making. 3.3 Facilitate timely and appropriate services to Residential Aged Care Facilities through the use of ehealth initiatives and promotion of best practice business models for delivery of aged care services by GPs and Allied Health in RACFs. 3.4 Maintenance of the Barwon Medicare Local Aged Care Reference Group with key stakeholders to enhance service delivery and communication between primary care, RACF and community aged care. Page 2 of 12

3 Strategic Objective 4 Facilitation of the implementation and successful performance of primary health care initiatives and programs Strategic Objective 5 Be efficient and accountable with strong governance and effective management 4.1 Work collaboratively with local Aboriginal and Torres Strait Islander providers to implement initiatives under the Closing the Gap (CtG) and Ca re Coordination and Supplementary Services (CCSS) Programs. 4.2 Continue to build relationships with local Aboriginal communities across sectors to facilitate identification of primary health system gaps and local service solutions through participation in regional committees and networks to support: broader consultation in identification of service gaps and local solutions promotion of local services and programs 4.3 Ongoing collaboration with LHNs, G21 and other local stakeholders to identify and implement local strategies which address prevention and early intervention. 5.1 Develop and implement a robust Continuous Quality Improvement Framework to support Barwon Medicare Local to meet the quality and safety standards applicable to Medicare Locals and our Clinical Services. 5.2 Development and implementation of practical data and knowledge management systems for Barwon Medicare Local. 5.3 Implementation and monitoring of Barwon Medicare Local Reconciliation Action Plan with keystakeholders. Page 3 of 12

4 Activities Table 1 SO KRA FP ACTIVITY NAME Improved access to primary health care services for older people living in a RACF or in the community 1 Aged Care Wound Management Service To provide timely and responsive services to residents in Residential Aged Care Facilities (RACFs) DURATION 1 July June 2015 Description Provision of allied health services (Wound Management Consultancy) to residents in RACFs. This service provides GPs and RACF staff with access to specialised wound management consultancy for residents with chronic and complex wounds and/or wounds which are not progressing based on treatments by GP and RACF staff. Access to service is initiated via a GP referral. This is an existing activity for Barwon MEDICARE LOCAL which will allow us continue with a service provided to GPs, RACFs and RACF Residents in 2013/14 Entire Barwon MEDICARE LOCAL region GPs, RACFs and residents with chronic and complex wounds. Service sub-contracted Performance information No. services provided No. services provided per RACF Collection of data to assess local need and quality of service Expected outcome Access to a Wound Management consultancy service for residents in RACF with chronic and complex wounds.

5 2 SO KRA FP ACTIVITY NAME Immunisation 2 Immunisation To maintain and/or improve immunisation coverage rates. DURATION 1 July June 2015 Description Provision of training and resources to General Practice with a specific focus on the use of the PEN Clinical Audit Tool and ACIR Registration and Reporting. Promotion of immunisation schedules and updates, vaccine storage, cold chain management and data logging via practice visits, phone support, newsletter and website material. Ongoing coordination of the regional Immunisation Reference Group with keystakeholders. Liaison with Refugee and Aboriginal and Torres Strait Islander stakeholders to identify barriers to immunisation for these groups. Provision of information and resources promoting the immunisation of children across all age groups to relevant keystakeholders in the Barwon Medicare Local region. Collection of qualitative and quantitative data to meet reporting requirements and maintain Barwon Medicare Local data This activity promotes increase immunisation of patients. Activities include education, provision of support and resources and engagement with keystakeholders which result improved health outcomes for children in the Barwon region. GPs, Practice Nurses, Immunisation Providers, Refugee and Aboriginal and Torres Strait Islander stakeholders. Activities will be delivered by Barwon Medicare Local. Performance information No. and type of support activities provided to General Practice No. Immunisation Reference Group Meetings and Attendance No. Immunisation related training events and attendance rates Report on barriers and enablers to improving immunisation rates for keystakeholders Expected outcome Maintain immunisation rates > 90% within the Barwon Medicare Local region for children therefore reducing the incidence of a range of childhood illnesses. Page 5 of 12

6 3 SO KRA FP ACTIVITY NAME HealthPathways 3 Diabetes/COPD/ Health Literacy/Obesity-Overweight Working with stakeholders to build relationships and increase engagement and develop clinical pathways to support assessment, management and referral of specific clinical conditions. DURATION 1 July June 2015 Description HealthPathways is a process that enables GPs, Specialists and other keystakeholders to meet and work through clinical pathway issues which are locally relevant. The outcome/s of workshops is an agreed clinical pathway which can be accessed via an online portal and used at the point of care. It provides information on how to assess and manage medical conditions and outlines referral processes to local specialists and other services. HealthPathways will continue to be implemented across the Barwon Medicare Local region which includes governance, clinical pathway development and evaluation. Focus for 2014/15 will include Diabetes, COPD and Obesity/Overweight as areas identified in the CNA process. This is an existing activity for Barwon Medicare Local which will allow us continue with the work commenced in and supports the development of localised clinical pathways by local providers. This ensures patients are assessed, managed and referred appropriately for their particular clinical condition at the point of care. GPs, Specialists, LHNs, Allied Health This is a joint initiative of Barwon Medicare Local and Barwon Health. HealthPathways development and maintenance is coordinated by Barwon Medicare Local. Performance information Number of clinical pathways developed Number of resource and referral pages developed Number of unique users Number of page views of website Number of page views per pathway Number of GPs and specialists participating in workgroups Evaluation of GP workgroup members satisfaction with process Survey of GP satisfaction with program Expected outcome Improving the patient journey through: Reduced attendances and reviews in Outpatients Departments Development of clinical pathways, resource pages and referral options Increased health/service literacy for GPs and other providers Improved relationships and communication between specialists and GPs Enhanced partnership activity between Barwon Medicare Local and LHNs More accurate appropriate referrals from primary to secondary care Page 6 of 12

7 4 SO KRA FP ACTIVITY NAME Secure Messaging 3 Service Cohesion in Early Years/Aged Care /AOD To improve communication and coordination between all healthcare providers to facilitate secure and timely transfer of patients clinical information. DURATION 1 July June 2015 Description Expand the implementation and use of ReferralNet to LHN s, GPs, Allied Health, Specialists and Diagnostic Providers to improve communication, service integration and coordination in the Barwon Medicare Local region. To continue to work with healthcare providers to link with the Health Identifier Service to enable SMD messaging allowing us to communicate securely with neighbouring regions. This is an existing activity for Barwon Medicare Local which will allow us expand the work undertaken by Barwon Medicare Local in previous years. It will provide education and support to providers to increase use of ReferralNet, link with the Health Identifier Service and support communication interoperability across regions in order to ensure efficient, timely and accurate exchange of patient information. GPs, Specialists, Allied Health, LHNs, Diagnostic Providers Activities will be delivered by Barwon Medicare Local Performance information No. of health providers connected to ReferralNet No. secure messages sent and received No. organisations registered for HI Services No. organisations registered and connected to ehealth Record Expected outcome Increased communication between health care providers via secure messaging Increased uptake of ReferralNet locally SMD interoperability established where possible Page 7 of 12

8 5 SO KRA FP ACTIVITY NAME Docs and Teens Program 4 Sexually Transmitted Infections amongst Young People Health Literacy To provide health promotion and/or preventative health initiatives aimed at addressing locally relevant risk factors DURATION 1 July June 2015 Description To increase youth access to local health services and increase young people s knowledge of services, health and ill health and risk behaviours through the delivery of the Docs and Teens Program in Secondary Schools within the Barwon Medicare Local region. This activity is an existing activity for Barwon Medicare Local directly providing education/information to young people and supports them to make informed decisions about their health and wellbeing and improve longer term health outcomes. GPs, Secondary Schools, Year 9 Students Activities will be delivered by Barwon Medicare Local and local GPs Performance information Number of schools participating in the program. Number of students participating in program. Evaluation surveys completed by students, teachers and GPs Number of GPs attending information and training sessions in relation to current trends and issues for young people Expected outcome Increase health literacy and knowledge of health information Increase willingness of young people to access services and decrease barriers Increase young people s knowledge of local health services Increase knowledge in sexual health and risk factors for young people Contribution to whole school approach to the teaching of sexuality education Page 8 of 12

9 6 SO KRA FP ACTIVITY NAME After-Hours Program 6 After-Hours/ Aged Care To provide accessible and effective after-hours primary care services in the region DURATION 1 July June 2015 Description Provision of funding to support after-hours service delivery across the region that meets funding guidelines and provides access to all sub-regions in the Barwon Medicare Local region Collection and analysis of service delivery and service model data by Barwon Medicare Local from funded services Provision of service level and aggregated after-hours data to all funded services providers to assist with quality improvement Ongoing coordination of an After-Hours Home Visiting and RACF Service Reference Group and liaison with service providers to monitor quality and efficiency of the after-hours services. Increase community awareness of after-hours services in the Barwon Medicare Local region including the GP After-Hours Helpline This activity is an existing activity for Barwon Medicare Local which will be maintained over 2014/15. The model has been reviewed in 2013/14 and will continue unchanged for the next 12 months. GPs, RACFs, Consumers Barwon Medicare Local will undertake community awareness, data collection and analysis activities. Funding will be provided to General Practices and Home Visiting Doctor Service to provide after-hours service delivery. Performance information No. After-Hours services provided by General Practice No. after-hours services provided to RACFs Report of barriers and enablers to effective and efficient after-hours service delivery by General Practice Expected outcome Improved access to after-hours services in the community and a potential reduction in attendance for non-urgent presentations to the Emergency Dept. Improved access to after-services in RACFs Increased awareness of after-hours services in the community Collection of data for the effectiveness of funding for after-hours service delivery Collection of evidence of enablers and barriers to the implementation of the after-hours model Page 9 of 12

10 7 SO KRA FP ACTIVITY NAME Aged Care Program Aged Care To provide timely and responsive services to residents in Residential Aged Care Facilities (RACF s) DURATION 1 July June 2015 Description Maintenance of the Barwon Medicare Local Aged Care Reference Group with key stakeholders to enhance service delivery and communication between primary care, RACF and community aged care Increase access to Telehealth within RACFs, general practices (outside of RA1 area) and specialists through th e installation of Clearsea Licenses and development and dissemination of a Barwon Medicare Local Telehealth Directory. Promote the use of ehealth initiatives in RACFs including secure messaging and PCEHR capability Promote awareness of after-hours services in the Barwon Medicare Local and amongst RACFs Identify best practice business models for delivery of aged care services by GPs and Allied Health in RACFs This is an existing activity for Barwon Medicare Local which will allow us to build on work commenced in 2013/2014 and will support increased access to health service for residents in RACFs requiring medical and allied health services. GPs, Practice Nurses, Specialists, Private Allied Health Providers, RACFs Activities will be undertaken by Barwon Medicare Local Performance information No. RACFs accessing telehealth No. Residents registering for ehealth Record Report on barriers and enablers to implementation of the ehealth Record in RACFs Report on development and promotion of aged care models Expected outcome Improved access to specialist care for residents in RACFs via telehealth. Improve coordination of care of residents in RACFs through increasing registrations with the ehealth Record. Improved awareness amongst RACFs of after-hours medical services. Development of a viable aged care business models to support increase service delivery to RACF by GPs and Allied Health providers. Page 10 of 12

11 8 SO KRA FP ACTIVITY NAME Rural Primary Care Health Access Access to allied health services and workforce development To increase access to primary care services in rural and remote areas of the Barwon Medicare Local region DURATION 1 July June 2015 Description Establish a health network with membership from each of the key health organisations in the rural and remote areas of the Barwon Medicare Local to: Identify and quantify allied health service needs. Work with key stakeholders and organisations to identify and develop possible service models that ensure best access to allied health services in rural and remote areas and use of resources using a social equity and cultural lens. Implement identified service models in the rural and remote areas of the catchment. Utilise ehealth service delivery and training technologies (tele/video conferencing, telehealth, webinars) To provide solo GPs in rural areas with access to locum support to maintain medical services in rural and remote areas via: Maintaining a local locum subsidy program for local GPs based on established criteria Continue to work with RWAV regarding administration of the program including enablers and barriers. This is an existing activity for Barwon Medicare Local. This work builds on the work undertaken as a part of Rural Primary Health Services (RPHS) funding and is working with local health care providers to improve the access and coordination of primary health services and provides direct clinical service to patients in rural areas. RA 2 areas of the Barwon Medicare Local region General Practice, LHN s and private Allied Health providers within the identified areas. Barwon Medicare Local will establish the network and work with partners to develop the service delivery model from Jul-Dec. Current arrangements for service delivery in the identified areas will be maintained until Dec 2014 with a view that service delivery would be sub-contracted to appropriate providers identified during service mapping and model development. Performance information No. and type of Allied Health services provided No. clients provided a service No. and type of stakeholders engaged and contributing to model development process No. locum subsidies provided and RA2 areas covered Expected outcome Increased access to allied health services in the rural and remote areas of the catchment in response to identified allied health needs. Improved collaboration and leveraging of existing resources in the rural and remote areas of the catchment between health and community services. Allied health service models implemented. Increased use of telehealth for service delivery in rural and remote areas Allied health workforce strategy documented implemented to ensure sustainability of models implemented. Increased understanding of cultural awareness amongst service providers in rural areas Page 11 of 12

12 9 SO KRA FP ACTIVITY NAME Clinician Support- Continuing Professional Development 2.1 Health Literacy/Diabetes/COPD/ AOD/Overweight and Obesity/STI s/oral Health Facilitate access to continuing professional development for GPs, Practice Nurses, Allied Health and other Primary Care staff which is based on local needs, promotes best practice, quality and safety and a multidisciplinary approach. DURATION 1 July June 2015 Description Facilitate access to continuing professional development for GPs, Practice Nurses, Allied Health and other Primary Care staff which is based on local needs, promotes best practice, quality and safety and a multidisciplinary approach. CPD events in 2014/15 will cover the following areas as identified in the CNA process: Health Literacy Diabetes Prevention and Management COPD Prevention and Management Alcohol and Other Drugs including early intervention, screening and oral health Overweight and Obesity STI s This activity builds on the CPD activities provided by Barwon Medicare Local and will provide education/information relating to specific areas identified through the CNA process to GPs, Practice Nurses and Allied Health. This supports health providers to better manage patients. General Practice, Practice Nurses, Allied Health providers Activities will be undertaken by Barwon Medicare Local utilising suitably qualified and experienced individuals/agencies to deliver CPD content Performance information No. and type of CPD events undertaken CPD attendance rates and primary care providers engaged Expected outcome Increased knowledge of GPs, Practice Nurses and Allied Health in regard to areas identified in CNA Links to other Barwon Medicare Local programs and initiatives and services supporting the early detection and management of patients Page 12 of 12

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