Activity Work Plan : Integrated Team Care Annual Plan

Transcription

1 Primary Health Networks Integrated Team Care Funding Activity Work Plan : Integrated Team Care Annual Plan Northern Queensland Primary Health Network When submitting this Activity Work Plan 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 via to on or before 15 July

2 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 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 at a later date. The Activity Work Plan template has the following parts: 1. The Integrated Team Care Annual Plan 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. 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

3 Annual Plan Annual plans for 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 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

4 1. (a) Strategic Vision for Integrated Team Care Funding Northern Queensland Primary Health Network s strategic vision of Making Health Better will be achieved by understanding need, strengthening partnerships and creating healthier communities. Our vision will be supported by aligning our strategies across six strategic objectives. Our activity work plan will be implemented by building a (1) coordinated, integrated and easy to navigate health system for both consumers, communities and health providers. A health system that is cohesive, structured and inherently connected, with patients getting the right service, at the right place, at the right time. Our vision is built upon (2) health intelligence and planning. We will ensure our consumers, communities and providers are well informed of their population health priorities and are empowered to take initiative to implement effective and efficient action locally that will produce a positive outcome. We will invest in (3) workforce capacity and capability. We will aim for a flexible and adaptable well-trained workforce (including non-clinicians), with the capacity and capability to deliver best care to patients while continuing to build skills through effective training and team work. (4) Strengthening partnerships and networking including leadership and advocacy will be key to our success. We will build strong partnerships and networking in primary care built on collaborative models, which strengthen relationships between health professionals, across the health sector and with consumers. Of key importance will be our high levels of (5) transparency, performance, quality and safety. We will aim for a strong framework of quality, safety and accountability in primary health care, based on improved information and quality assurance systems to support measurement, feedback and quality improvement for providers, and greater transparency for consumers and funders. This includes clinical and organisational governance, and risk management. We will invest in a strong (6) prevention and health promotion system. It will be standard practice to tackle the social determinants of health and wellbeing with emphasis on health promotion, prevention, screening, and early intervention. This will be implemented by high functioning collective impact partnerships, supporting local action on identified health promotion and prevention priorities, including local government and other relevant stakeholders. The objectives of the NQPHN involvement in Aboriginal and Torres Strait Islander Health, is making health better that is free of racism and inequality and all Aboriginal and/or Torres Strait Islander people have access to health services that are effective, high quality, appropriate and affordable. NQPHN acknowledges the importance of social determinants of health as platform to improve health outcomes. NQPHN aims to commission a range of Aboriginal and Torres Strait Islander health initiatives to NQ Indigenous people that; Implement innovative and locally-tailored solutions Aboriginal and Torres Strait Islander Health programs/services, based on community need; and Work to address gaps in Aboriginal and Torres Strait Islander Health service provision, particularly in rural and remote communities within NQPHN. 4

5 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 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? Not applicable Proposed Activities Six-month transition phase Anticipated start date of ITC activity Will the PHN be working with other organisations and/or pooling resources for ITC? NQPHN will retain existing arrangements until the 31 st December 2016 with current providers of Care Coordination and Supplementary Services (CCSS) and Improving Indigenous Access to Mainstream Primary Care (IIAMPC) programs. This will ensure service continuity whilst the new Integrated Team Care (ITC) program arrangements are being commissioned in anticipation of 1 January full transition to the new ITC models of care. NQPHN s new ITC program delivery will commence from 1 January There are natural patient flows in Queensland whereby people move from communities in Western Queensland, and the Gulf of Carpentaria to the east coast to access health services, primarily in the regional centres of Cairns and Townsville. NQPHN will establish protocols with Western Queensland PHN (WQPHN) to establish arrangements that support patients who frequently move between the WQPHN region, to access services in the NQPHN region. Opportunities for co-commissioning will be explored. 5

6 Service delivery and commissioning arrangements NQPHN will have two different approaches to the ITC program, in different service delivery settings, that will each warrant a different approach to commissioning; 1. Aboriginal Medical Services ITC model 2. Mainstream General Practice ITC model In order to inform relative community (LGA) resource allocation, NQPHN will use a population and needs based resource allocation tool, that employs a weighted capitation formula based on; Population size Age/Sex Groups Socio-Economic Deprivation (SEIFA) Proportion of Aboriginal and Torres Strait Islander people Remoteness Unavailability of services Disease status, and Social cohesion (as indicated by employment/school attendance rates) Aboriginal Medical Services ITC Model NQPHN will directly engage with the Northern Aboriginal and Torres Strait Islander Alliance (NATSIHA) to deliver the Aboriginal Medical Services ITC model across the entire NQPHN footprint. NATSIHA has been in existence since early 2010, and is a collective consortium of many ACCHOs in our NQPHN footprint. Through NATSIHA, NQPHN will collaborate and engage our Aboriginal and Torres Strait Islander people and communities to design an ITC program that is equitably distributed, and NQPHN will support NATSIHA to establish organisational functions and processes to support effective ITC program delivery. Through this approach and model design NQPHN will foster a collective approach with Aboriginal Medical Services (AMSs), and Aboriginal Community Controlled Health Organisations (ACCHOs) that fosters collaboration and partnership. Indigenous Health Program Officers (IHPOs) will have responsibility for consortium capacity building, support and coordination; in addition to working closely with IHPO peers in the Mainstream General Practice ITC model to coordinate activities and services across the two models. Depending on the model co-design outcomes, Indigenous Outreach Workers (IOW s) and Care Coordinators (CC s) and Supplementary Services fund pool may be either; a separate team of shared resources delivering services working across various AMS s or ACCHO s, or may be allocated to individual AMS s or ACCHO s toward embedded positions and services; consistent with the ITC program guidelines. 6

7 Decision framework Mainstream General Practice ITC model NQPHN will approach the market seeking a consortium to deliver the Mainstream General Practice ITC Model across the entire NQPHN footprint. It is anticipated that this approach to market will open with an Invitation to Apply or Request for Tender in September Indigenous Health Program Officers (IHPOs) will have responsibility for mainstream General Practice and primary health care capacity building, support and coordination; in addition to working closely with IHPO peers in the Aboriginal Medical Services ITC model to coordinate activities and services across the two models. Depending on the model co-design, Indigenous Outreach Workers (IOW s) and Care Coordinators (CC s) and Supplementary Services fund pool may be either; a separate team of shared resources delivering services working across various mainstream practices with an identified high proportion of Aboriginal and Torres Strait Islander patients, or may be allocated to individual General Practices toward embedded positions and services; consistent with the ITC program guidelines. NQPHN has the highest Aboriginal and Torres Strait Islander (~83,000) population in Qld. The Aboriginal and Torres Strait Islander population are among the most vulnerable with our PHN. Our PHN Indigenous mean age of death is markedly younger (~60 years) compared with non-indigenous (~76 years); a sixteen-year gap in life expectancy. Aboriginal and Islander Community Controlled Health Services data indicates that Diabetes prevalence amongst Indigenous adults is estimated to be between 15 25% of persons. Torres and Cape report over 70% of overweight and obese persons. There is a high proportion of Indigenous adults at risk of renal disease was over 30%, In our PHN, we have a high proportion of Aboriginal and Torres Strait Islander persons who report high levels of disadvantage (SEIFA) low education achievement, overcrowded housing, low access to transport/ private vehicles and poor access to services. The National Aboriginal and Torres Strait Islander Health Plan highlights the need for a multifaceted approach to closing the gap in health outcomes, includes a shared collaborative model between ACCHOs and mainstream primary health care. A review of resource distribution in the NQPHN footprint informed by CCSS and IIAMPC program data and reporting has determined that resources have previously been distributed in a manner that is not consistent with need, or informed by an evidence based approach. NQPHN will use the aforementioned relative community (LGA) resource allocation tool to inform decision making in addition to qualitative data gathered through engagement with; Primary health care providers, and General Practice (including Aboriginal Medical Services, through NATSIHA and the NQPHN AMS advisory group), Indigenous community- including a planned Broader engagement at different Indigenous specific community events (i.e. NAIDOC etc.). Non- government and community groups, 7

8 Decision framework documentation ITC Workforce Health and social services and government departments and agencies for the delivery of Care Coordination program. During the period from July to September 2016, community engagement will be undertaken throughout the NQPHN region titled Our Yarn, Our Health, Our Future. The IAP2 model of stakeholder and community engagement will guide the engagement methodology, predominantly through informing and consultation. Participatory Action Research information will be captured based on reflection, data collection, and action that aims to improve health and reduce health inequities through involving the people who, in turn, take actions to improve their own health. The information obtained will be analyzed to identify the core themes within each region and documented within the engagement report and in turn inform the appropriate commissioning approach. NQPHN will establish an Aboriginal and Torres Strait Islander Expert Advisory Group, including members and governance arrangements that feed into NQPHN Community Advisory Groups and Clinical Councils. This Expert Advisory group with be responsible for reviewing all collated engagement information, other available data, and ultimately informing and reviewing ITC commissioning plans and endorsing program design. Yes NQPHN will employ two relationship coordinators and an ITC program lead to oversee the two consortium, support quality improvement and strong collaboration, and prevent duplication of any systems, processes and services. These staff will ensure that the ITC program has strong regional coordination of ITC activities across a large and diverse area, and multiple consortium, which necessitates a central coordination and capacity building function that must be provided by NQPHN. These staff will take a policy and leadership role within NQPHN. They will function as team leaders to ensure there is a focus on Indigenous health and aim to improve the integration of care across the region. This work includes needs assessment and planning, developing multi-programme approaches and cross-sector linkages, and supporting both Outreach Workers and Care Coordinators including coordinating ITC workforce development activities and quality improvement. These positions will act as primary ITC program leaders and will provide direction to other consortium based ITC staff. Aboriginal Medical Services ITC model Half of the staffing resources will be allocated to the Aboriginal Medical Services ITC Model including; 2 Indigenous Health Project Officers FTE Care Coordinators 6-7 FTE Indigenous Outreach Workers 8

9 Mainstream General Practice ITC model Half of the staffing resources will be allocated to the Mainstream General Practice ITC Model including; 2 Indigenous Health Project Officers FTE Care Coordinators 6-7 FTE Indigenous Outreach Workers 9