activity work plan 2018-2019 - sydney north health network · activity work plan 2018-2019 (core...

1 Activity Work Plan 2018-2019 (Core Funding, General Practice Support Funding, After Hours Funding) V1 – 16 April 2018 (D18-634620)

Activity Work Plan 2018-2019: Core Funding General Practice Support Funding After Hours Funding

OverviewThe 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 rightplace at the right time.

This Activity Work Plan covers the period from 1 July 2018 to 30 June 2019.

1. (a) Strategic Vision for PHN

The Sydney North Primary Health Network (SNPHN) operates the Northern Sydney PHN, one of 31 PHNs, and is focused on enabling the 907,000 people in the Sydney North region to care for their own health and effectively navigate a complex healthcare system. This is achieved by providing better information, education, and networking opportunities for health professionals, establishing connections across the health system, and working with partners to deliver a better experience for health providers and better healthcare for the community.

The SNPHN Board has consulted and developed a renewed strategic plan and vision for the organisation for 2018 – 2023 which is currently being finalised. Following the July 2018 Board meeting, SNPHN will publish and promote the updated strategic vison on the website.

The link below provides access to the current SNPHN strategic vision:

https://sydneynorthhealthnetwork.org.au/about-us/our-purpose

Northern Sydney PHN

https://sydneynorthhealthnetwork.org.au/about-us/our-purpose


The draft strategic vision for SNPHN 2018 – 2023 is outlined below for reference:


1. (b) Planned PHN activities

– Core Flexible Funding Stream 2018-19

Proposed Activities - copy and complete the table as many times as necessary to report on each activity

Activity Title / Reference (eg. CF 1) CF 1 – Community Health – Vulnerable groups

Existing, Modified, or New Activity Existing

Program Key Priority Area

Population Health

Including: • CALD• Aged Care• Young people• Indigenous Health• Homeless• Mental Health and Drug and Alcohol

Needs Assessment Priority Area (eg. 1, 2, 3)

Consumer engagement and health literacy; health promotion activities relating to population health Behavioural Lifestyle Risk Factors.

• Cancer screening – Page 2• Access – Consumer engagement and health literacy – Page 5, 6• Aboriginal and Torres Strait Islander Health – Page 7, 8• Health of Older People – Page 9, 11• Culturally and Linguistically Diverse – Page 12

Aim of Activity Targeted community capacity building to enhance access to primary care for vulnerable populations and to improve health outcomes.

Description of Activity Through community activities including health talks, GPs in Schools, CALD health programs:

• Continue to deliver and expand the GPs In Schools program, across the region, introducing new partners and sponsors.


• Continue to deliver and expand the healthy living program (Smoking, Nutrition, Alcohol, Physical Activity and Obesity management), across the region working in partnership to target vulnerable groups, a component of this activity may include commissioning of digital technology to enhance patient engagement and health literacy to support direct patient care.

• Support compassionate communities focusing on youth, aged care, and palliative care.• Build upon NSPHN community engagement strategy to continually engage local population,

with People Bank portal – promoting sign-up and developing program of activities to support the community members engaged. Aboriginal and Torres Strait Islander Health

• Continue to work with consumers and other stakeholders to increase understanding of issueswith current system including barriers (actual or potential) to accessing services.

• Continue to work with local community, partners, LHD and primary care to promote betteraccess and uptake of regional Aboriginal Health services (including NSPHN Aboriginal Healthcommissioned services and activities) and the local Aboriginal Health GP outreach unit.

• Continue to support general practice and partners to increase IH PIP registration andpercentage of Aboriginal and Torres Strait Islander peoples who receive MBS715 healthassessment.

Target population cohort Targeting vulnerable groups (particularly lower socio-economic, CALD, Aboriginal, young people), however supporting improved health literacy and access to primary care for entire NSPHN population.

Consultation - HSI Component

NSPHN has undertaken extensive community and sector consultation in the design of the above activities. NSPHN will continue to utilise the NSPHN Commissioning Evaluation Framework, based on the quadruple aim, to continually monitor and evaluate activity – including patient/consumer and provider experience measure, which will inform any future service redesign or areas for service improvement.

Collaboration - HSI Component

Northern Sydney PHN will work with stakeholders across the health and social care economy to set the strategic direction, to drive service improvements and achieve system change beyond their direct circle of control. Relationships will build and will support co-design and co-delivery of services. The PHN will work in partnership with the Local Health District on joint activities around key vulnerable population groups, overseen by the PHN/LHD Joint Executive Council and will work with Local Councils


(local Government Areas), schools, service providers, community groups and primary care providers to support activity delivery and enhance access to services by vulnerable populations.

HSI Component – Other NSPHN staff will undertake this activity including: planning, contract administration (where required) using the NSPHN Commissioning Evaluation Framework, monitor and evaluate activities, provide stakeholder and relationship engagement, including ongoing community and stakeholder consultation.

Indigenous Specific Part of this activity is dedicated to supporting Aboriginal and Torres Strait Islander people.

Duration This major area of activity will continue in 2018/19.

Coverage The Northern Sydney PHN activities will occur across the entire PHN region.

Commissioning method (if known)

The Northern Sydney PHN will adopt a collaborative approach to commissioning, where required, and will work in partnership for relevant elements of this activity to deliver. Where possible, the NSPHN will use an open tender approach to market. The decision on approach will be based on a market analysis, looking at the current dynamics in the region against what an ideal market might look like and where characteristics do not align, look at how the NSPHN can support market development whilst addressing the needs identified. The procurement method will be chosen based on this analysis of the market.

Decommissioning Nil decommissioning required for this activity for 2018/2019.


Funding from other sources Contribution from community and local government sources. Amounts ($) to be confirmed.


Activity Title / Reference (eg. CF 1) CF 2 – Building Primary Healthcare Capacity

Existing, Modified, or New Activity Modified OP 1 – Building Primary Care Capacity

Program Key Priority Area Select one of the following: Workforce


• Health of Older People – pg 9 – 11• Cancer screening & immunisation – pg 2-3• Urgent Care – pg 4• CALD – pg12

Aim of Activity To build the capacity of Primary Health Care in the region to deliver high quality, patient-centred, comprehensive, coordinated, integrated, accessible care.

Description of Activity

As a result of identified local needs and national headline indicators, we will undertake targeted commissioning of general practices, using an improvement collaboratives approach to:

• Improve care of patients with Dementia• Improve management of patients with chronic disease• Increase rates of breast, bowel and cervical screening• Increase rates of fully immunised 5yo children• Reduce rates of preventable hospitalisations through adoption of PCMH “building

blocks”. Sixty-nine practices were actively engaged in these activities in the previous year and we expect this number to increase. An estimated 330,000 patients will be directly impacted as a result of this activity.

• Commission a platform for HealthPathways to enable improved access to services for patients


• Review outcomes of the commissioned Palliative Care Capacity Building in RACFs initiative with a view to expanding reach. Provider to be re-commissioned pending outcomes of the evaluation report due August. The funding is to expand reach of the service to additional RACFs, not to perform the review/evaluation, which is already in progress.

Target population cohort

General practices

Populations diagnosed with at least one of the targeted focus areas

Residents of Aged Care Facilities and their families


NSPHN has undertaken extensive community and sector consultation in the design of the above activities. NSPHN will continue to utilise the NSPHN Commissioning Evaluation Framework, based on the quadruple aim, to continually monitor and evaluate activity – including patient/consumer and provider experience measures, which will inform any future service redesign or areas for service improvement.

• Consultation for PCMH & QI has occurred and continues in collaboration with participatingpractices.

• Consultation for QI and HealthPathways initiatives has occurred and will continue with therelevant governance structures (advisory groups) set up to oversee and monitor

• Consultation for Palliative Care RACF initiative has occurred and is planned to occur againafter the independent evaluation results have been released (Aug/Sep 18)


GP Commissioning:

• General Practices (program participants)

HealthPathways:

• Northern Sydney Local Health District (NSLHD) (joint oversight roles)

Palliative Care in RACFs:

• HammondCare (Commisioned provider)• UTS (independent evaluator)• NSLHD (service provider)• Primary care providers (service providers)


• Consumers & their families (beneficiaries)

HSI Component – Other NSPHN staff will undertake planning, contract administration (where required) using the NSPHN Commissioning Evaluation Framework, monitoring and evaluation activities, provide stakeholder and relationship engagement, including ongoing community and stakeholder consultation.

Indigenous Specific No

Duration

GP Commissioning – already commenced, anticipated completion Q3 (Jan-Mar 19)

QI & HealthPathways– ongoing full year

Palliative Care in RACFs – Evaluation results due Aug/Sep 2018.

Coverage Whole PHN Region


NSPHN uses its commissioning evaluation framework to assess and monitor commissioned service performance.

The success of the PCMH program in 2017/18 and the positive feedback received from participants has led to the re-commissioning of the leadership program for 2018/19.

Final evaluation results for the Palliative care in RACFs initiative will influence the decision to re-commission in 2018/19, however early results have been promising.


Funding from other sources

Funding from other sources N/A


Activity Title / Reference (eg. CF 1) CF 3 – Care Coordination Support

Existing, Modified, or New Activity Modified - combination of existing activities and introduction of new activities

Program Key Priority Area

Population Health

Including: • CALD• Aged Care• Chronic and Complex Health• Young people• Indigenous Health• Mental Health and Drug and Alcohol


• Cancer screening – Page 2• Access – Consumer engagement and health literacy – Page 5, 6• Aboriginal and Torres Strait Islander Health – Page 7, 8• Health of Older People – , 11• Culturally and Linguistically Diverse – Page 12• Urgent Care - Page 3, 4

Aim of Activity Establishing a program of care coordination and navigation support across primary health care, mental health and the community to support both consumers and providers, particularly general practitioners.

Description of Activity SNPHN have commissioned a range of services to support hospital avoidance. These include a discharge follow up and care coordination service for people at risk of hospitalisation or re-admission, a social work service to support GPs for people with chronic and/or complex health care


conditions who are at risk of hospital admission or re-admission, a chronic disease management program (WellNet). We intend to commission nurse-led clinics this year as well.

• Identify and design potential joint initiatives in areas of identified need (e.g. General Practicesupport; Care coordination – chronic disease; Aboriginal health; urgent care; aged care;palliative care; youth; mental health; AoD; vulnerable groups; and RACFs)

• Design palliative care coordination project, with partners (e.g. Private Health Insurers) andwider primary care and community sector with local communities and consumers.

• Establish a further roll out of program of care coordination initiatives in the community, e.g.nurse led clinics; service navigation initiatives e.g WellNet, concierge – based on identifiedneeds and opportunities for service development.

Target population cohort Targeting vulnerable groups particularly (lower socio-economic, CALD, Aboriginal, young people), however supporting improved health literacy and access to primary care for entire NSPHN population.


NSPHN will undertake extensive community and sector consultation in the design of the above activities. NSPHN will utilise the NSPHN Commissioning Evaluation Framework, based on the quadruple aim, to continually monitor and evaluate activity – including patient/consumer and provider experience measure, which will inform any future service redesign or areas for service improvement.


Northern Sydney PHN will work with stakeholders across the health and social care economy to set the strategic direction, to drive service improvements and achieve system change beyond their direct circle of control. Relationships will build and will support co-design and co-delivery of services. The PHN will work in partnership with the Local Health District on joint activities around key vulnerable population groups, overseen by the PHN/LHD Joint Executive Council and will work with Local Councils (local Government Areas), schools, service providers, community groups and primary care providers to support activity delivery and enhance access to services by vulnerable populations.

HSI Component – Other

NSPHN staff will undertake this activity including: community and sector consultation and planning, contract administration (where required) using the NSPHN Commissioning Evaluation Framework, monitor and evaluate activities, provide stakeholder and relationship engagement, including ongoing community and stakeholder consultation.


Indigenous Specific Part of this activity is dedicated to supporting Aboriginal and Torres Strait Islander people.

Duration This major area of activity will continue in 2018/19.




Decommissioning Nil decommissioning required for this activity for 2018/2019.


1. (c) Planned PHN activities– Core Operational Funding Stream: Health Systems Improvement 2018-19– General Practice Support Funding 2018-19

Please complete this table for Core Operational Funding Stream b) Health Systems Improvement (HSI)3 and planned activities under the General Practice Support Funding Schedule only. Stream a) Corporate Governance, should not be included. Do not include HSI activities previously specified in 1. (b) Planned PHN activities – Core Flexible Funding 2018-19.


Activity Title / Reference (eg. HSI or GPS) HSI 1 – Health Intelligence

HSI/GPS Priority Area Population Health Planning

Existing, Modified, or New Activity Existing activity - with inclusion of new activities to progress data linkage across the region

Aim of Activity

NSPHN will further develop the health intelligence infrastructure to successfully plan and deliver health services and support the integration of the wider primary health care sector. This activity will be informed and underpinned by analysing and linking a range of data sets to intelligent inform activity. This activity will be core to supporting general practice to access timely information and will build capacity to understand local health priorities of their populations and develop appropriate strategies to address and drive improved health outcomes.

In addition, the NSPHN annual planning and consultation with the primary care sector wider community will provide a sophisticated level of understanding to inform subsequent health service planning and commissioning activity.


• Undertake annual planning processes, including review of population health data andestablishment of outcome measures in needs assessment process and confirm priority areas andareas of need against existing needs analysis

• Build systems for improved performance analysis/reporting against the PHN ProgramPerformance and Quality Framework; practice data; and commissioning data utilising Clicksense.

• Establish a shared data linkage program with the Local Health District.


• Establishment of new joint research initiatives with universities.• Establishment and early implementation of the GP data linkage pilot (NSW Ministry of Health).• Work with the PHN National Data Steering Group to build and implement national health

intelligence platform in preparation for the QI PIP.

Supporting the primary health care sector

The primary health sector will benefit from having access to enhanced quality data, to drive and support continual service improvement, provider and patient care and experience, by identifying local health population priorities. This will specifically support and prepare General Practice for the QI PIP roll out.

Better linkage with multiple data sets will also enable a whole of system approach to health service planning and will provide further intelligence to inform PHN activities and subsequent commissioning.

Collaboration

Northern Sydney PHN will work with stakeholders across the health and social care economy to set the strategic direction, to drive service improvements and achieve system change beyond their direct circle of control. The PHN will work in partnership with the Local Health District on joint activities around key vulnerable population groups, and access to relevant data sets and will be overseen by the PHN/LHD Joint Executive Council.

In addition, NSPHN will seek to work with the NSW Ministry of Health to develop data linkage strategies, and will work closely with service providers, community groups and primary care providers to support delivery to support health intelligence-related activity.

Duration This area of activity will continue in 2018/19.


Expected Outcome

Process Indicator: That NSPHN has undertaken a range of annual needs assessment and planning activities. Process Indicator: That commissioned services have engaged with local community in design, delivery, monitoring and evaluation of services. Output indicator: Proportion of Northern Sydney PHN general practices participating in data sharing activities.


Commonwealth funding

Planned General Practice Support Funding Expenditure 2018-19 (GST Excl.) – Commonwealth funding

N/A

Planned Expenditure 2018-19 (GST Excl.) –

Funding from other sources

N/A

Funding from other sources NSW Ministry of Health funding and support for GP Data Linkage pilot program. Amount ($) to be confirmed.


Activity Title / Reference (eg. HSI or GPS) HSI 2 - System Integration

HSI/GPS Priority Area System Integration

Existing, Modified, or New Activity Modified – NP1. Access & Navigation

Aim of Activity To work collaboratively with partners to enhance person centred, integrated primary health care services in the region, with a focus on priority populations (aged, youth and chronic & complex).


• Continue to jointly plan and develop new HealthPathways in Cancer, Gynaecology, Cardiology, Surgery and other agreed workstreams and strengthen service mapping with private sector

• Collaboratively re-design services in the areas of aged care (frailty) and palliative care (accelerating GP consultation and development and piloting of screening, assessment and management tools for the Frailty project and GP consultation and collaborative re-design of the community palliative care project)

• Strengthen shared models of care for diabetes, antenatal and “hospital in the home” services• Collaboratively design an approach to support older people to remain healthy and in their homes

and communities for longer

• Review youth services and identify opportunities to collaboratively work with local councils, businesses and wider stakeholders to expand youth services in the region.


The two dot points have been amended to reflect SNPHN’s activity across primary health care and is not a duplication of activity within the Mental Health Schedule – refers to all youth health services.


Primary care will be supported through:

• Support to access and navigate available services• Re-design services to ensure the role of general practice is strengthened and aligned with

Person Centred Medical Home principles and best practice integrated care frameworks

Collaboration

• Consumers – co-design• NSLHD – co-fund HealthPathways, governance, joint-planning, data sharing, co-design• Clinicians from across primary and acute settings – participants in HealthPathways work groups• Private Hospitals – co-design, service mapping• Private Health Insurers – potential co-funders, co-design• Ministry of Health – potential co-funders• Youth/mental health – governance, joint-planning, data sharing, co-design

Duration Ongoing for 2018/19

Coverage Whole PHN region

Expected Outcome

• Reduction in avoidable hospital admissions• Improved clinician experience and ability to navigate local system• People get the right care, at the right time, in the right place• Improved efficiency and effectiveness of mental health services for youth and older people


Funding from other sources Local Health District funding for integration activities to be confirmed. Amount ($) to be confirmed.


Activity Title / Reference (eg. HSI or GPS) HSI 3 – Stakeholder Engagement

HSI/GPS Priority Area System Integration and Workforce

Existing, Modified, or New Activity Existing activity - with inclusion of new activities to progress data linkage across the region

Aim of Activity Working collaboratively across the sector, including consumer engagement, to enable optimal services in primary health care and to support growth of joint opportunities that will enhance and strengthen primary health care.


• Identify metrics for allied health engagement with the PHN• Review general practice engagement metrics and ensure programs are designed to strengthen

engagement of practices.• Continue to promote NSPHN brand and achievements through strategic marketing• Maintain strong website and social media functioning• Strengthen primary health care engagement and value with the PHN• Identify and build new relationships with critical partners to ensure future success and

sustainability of programs and services


NSPHN will continue to support general practice and wider primary care by seeking to understand the most optimal approach to supporting continual service and quality improvement, whilst providing activities and initiatives that enable and facilitate enhanced awareness, access and navigation to a range of primary health care, NSPHN and wider health services that support both providers and patients.

Collaboration Northern Sydney PHN will work with stakeholders across the health and social care economy to set the strategic direction, to drive service improvements and achieve system change beyond their direct circle of control.


NSPHN will continue to proactively engage, support and identify areas for further service development with general practice and the wider primary health care sector.

Duration This area of activity will continue in 2018/19.


Expected Outcome • Strong relationships with stakeholders• Commissioning processes include representation from a broad range of stakeholders• Commissioned services adequately address local need


Activity Title / Reference (eg. HSI or GPS) GPS 1 - Core Practice Support

HSI/GPS Priority Area General Practice Support

Existing, Modified, or New Activity Modified – OP 1 Building Primary Care Capacity

Aim of Activity To enhance the capacity of General Practice to deliver high quality, safe, evidence-based care to their communities and respond to local population health needs.



• Continuously assess and monitor needs and capacity of general practices to inform programdevelopment and commissioning of services

• Support practice accreditation• Support practices with low immunisation rates• Support adoption and use of digital health technologies• Support practices to prepare for QI PIP – data extraction, data cleaning, data quality• Provide networking and professional development opportunities that align with local need and

national priorities• Continue to deliver and expand the Primary Care Nurse Transition Program, to support

graduate nurses in their first year and provide an alternative career pathway• Assess workforce stress and co-design a program to support clinician wellbeing (Caring for the

Carers)


Primary care will be supported through the range of activities listed. These strategies are designed to continuously assess needs and build the capacity of general practice to:

• explore new and more efficient ways of working• strengthen existing networks and develop new ones• facilitate spread and scale of innovative ideas and examples of excellence• respond to local changes in population health needs• expand career pathways for primary care nurses• minimise stress/burnout and promote clinician wellbeing

Collaboration

• General Practices – co-design• Accrediting agencies (e.g AGPAL/ QIP) – data sharing, resource support• Public Health Unit (data sharing, co-delivery)• Australian Digital Health Agency – governance, strategic support, resource support• Education Advisory Committee (multidisciplinary) – governance, co-design

Duration Ongoing for 2018/19

Coverage Whole PHN region

Expected Outcome • General practice is engaged and involved in PHN commissioning activities (identifying need, co-designing new approaches, procuring/re-designing services and ongoing monitoring)


• Primary Care services are provided with the skills to implement continuous qualityimprovement

• Primary Care is able to respond appropriately to local population health needs

3 HSI funding is to be used to deliver core functions within the PHN program such as population health planning, system integration and stakeholder engagement, as well as support to general practice which is not funded under the General Practice Support Funding Schedule. PHNs are able to use flexible funding to commission referral or health pathways activities (including non-staff costs such as ‘Streamliners’) but all associated PHN staff costs must be funded from HSI funding. HealthPathways activity to be undertaken by commissioned services should be separately identified as a Core Flexible Activity in 1. (b) Planned PHN activities – Core Flexible Funding Stream 2018-19.

PHNs cannot commission frontline services using HSI funding. PHNs may use HSI funding to subcontract specific activities under this stream, for example a health data analyst or consultant may be contracted to identify priorities for improved care coordination. Contracted or consultant arrangements are particularly appropriate for time-limited and specialist projects.

Practice support is to be provided through HSI funding and must be primarily delivered through PHN employees. Practice support cannot be commissioned out to a third party. Practice Support includes general practice support not funded under the General Practice Support Funding Schedule and support provided by your PHN to other practices, eg. allied health practices.


4. (a) Strategic Vision for After Hours Funding

The Northern Sydney PHN intent is to align after hours with the strategic vision of the organisation as a whole, which is to achieve better health and better care for the community, in collaboration with local stakeholders, including and most importantly the end user.

Furthermore, we believe the strategic focus of addressing after hours needs to be considered within the context of a broader system view of urgent care.

Our PHN seeks to:

• Maximise the contribution of community-based providers and health professionals as bothproviders of care and influencers of patient-decision making;

• Continue to influence development of appropriate clinical pathways; and

• Leverage data and technology to enhance and facilitate the entire after hours’ system andimprove the co-ordination of services, the integration of care, and both consumers’ andproviders’ experience of the system.

There is continued interest and an expressed commitment from stakeholders in the region to engage in the Northern Sydney After Hours Network. This leadership group provides a basis on which to drive system accountability and performance from the multiple organisations and providers. Integral to the Network is the continuance of a system-wide performance framework supported by shared data and aggregated performance reporting.

Over the next year, we aim to:

• Continue to build and maintain consumer awareness of alternatives to emergency departmentsafter hours, especially for target cohorts such as CALD, frequent ED attenders, those withcomplex health and social needs.

• Build the capability of general practice and primary care in the afterhours timeframe as skilled,patient-centred care providers.

• Monitor commissioned services in alignment with the NSPHN Commissioning EvaluationFramework and support them to continuously improve.

• Continue to facilitate the after-hours network for the Northern Sydney region.

• Support the design and implementation of digital health and enabling technologies across theurgent care system.

• Improve the consumer journey through the afterhours system.


4. (b) Planned PHN Activities

– After Hours Primary Health Care Funding 2018-19


Activity Title / Reference (eg. AH 1) AH 1 – Improved Access to Community Based Services

Existing, Modified, or New Activity Modified AH 1.1

Needs Assessment Priority Area (eg. 1, 2, 3) Urgent Care – pg 3 - 4

Aim of Activity Improve access to community-based services to reduce demand on after hours and emergency services.


• Continue to monitor access to and availability of after hours services across the region• Support uptake of community based commissioned after hours services• Monitor commissioned after hours services against the NSPHN commissioning evaluation

framework to inform continuous quality improvement

Target population cohort People with chronic and complex health conditions.

Consultation

NSPHN will continue to undertake extensive community and sector consultation in the design of the above activities. NSPHN will utilise the NSPHN Commissioning Evaluation Framework, based on the quadruple aim, to continually monitor and evaluate activity – including patient/consumer and provider experience measures, which will inform any future service redesign or areas for service improvement.

Collaboration

Northern Sydney PHN will work with stakeholders across the health and social care economy to set the strategic direction, to drive service improvements and achieve system change beyond their direct circle of control. The PHN will work in partnership with the Local Health District, NSW Ambulance, Private Health Insurers, Medical Deputising Services, General Practice, Pharmacy, Aged Care Facilities and consumers on joint activities to support hospital avoidance and support co-design and co-delivery of services.



Duration Continuous for 2018/19

Coverage Whole PHN region.

Commissioning method (if relevant)



Activity Title / Reference (eg. AH 1) AH 2 – Access, Navigation and Co-ordination


Needs Assessment Priority Area (eg. 1, 2, 3) Urgent Care – pg 3 – 4

Health of older people – pg 9-10


Aim of Activity Build system capacity to monitor and respond to urgent care needs to ensure people get the right care at the right time in the right place.


• Continued facilitation and strengthening of after-hours provider network to supportunderstanding and clarity on the roles of different services and health providers in providingurgent care

• Provide professional development opportunities for primary health care providers to increaseconfidence and skills to triage appropriately, identify deterioration early and manage urgentcare issues to minimise the chance of crisis presentations

• Support utilisation of digital health technology to facilitate clinical handover and continuity ofcare between urgent care providers - Extensive consultation with stakeholders demonstratesthat barriers to care co-ordination and clinical handover are contributing factors to crisispresentations in the after hours period. To address this, we will work with local urgent careproviders to support the use of digital health technology to enhance continuity of care. E.g.supporting urgent care providers, such as ambulance paramedics and GPs, to securelymessage referrals / event summaries, including commissioning of required hardware, softwareand training to ensure adoption and use.

Target population cohort People requiring urgent care

Clinicians

Consultation


Collaboration

Northern Sydney PHN will work with stakeholders across the health and social care economy to set the strategic direction, to drive service improvements and achieve system change beyond their direct circle of control. The PHN will work in partnership with the Local Health District, NSW Ambulance, Private Health Insurers, Medical Deputising Services, General Practice, Pharmacy, Aged Care Facilities and consumers on joint activities to support hospital avoidance and support co-design and co-delivery of services.








Activity Title / Reference (eg. AH 1) AH 3 – Consumer Engagement & Health Literacy



Urgent Care – pg 3 – 4

Access – pg 5

Health of older people – pg 9-11


CALD – pg 12

Mental Health – pg 14

AOD – pg 20

Aim of Activity Increase community awareness of and capacity to navigate local health services to reduce inappropriate demand on after hours and emergency services.


Continue targeted community awareness campaigns to improve awareness of and appropriate use of after-hours and emergency services.

Campaign plan includes material to be distributed via targeted communication channels including Tonic media, News Xtend, Website advertising. Example collateral can be found on our website https://sydneynorthhealthnetwork.org.au/programs/after-hours/ It also includes commissioning GP speakers to present to students of the NSW Tafe (Northern Sydney Institute) Adult Migrant English Program.

Target population cohort CALD, parents of young children, elderly and vulnerable populations.

Consultation


Collaboration

Northern Sydney PHN will work with stakeholders across the health and social care economy to set the strategic direction, to drive service improvements and achieve system change beyond their direct circle of control. The PHN will work in partnership with the Local Health District, NSW Ambulance, Private Health Insurers, Medical Deputising Services, General Practice, Pharmacy, Aged Care Facilities, local councils and consumers on joint activities to support hospital avoidance and support co-design and co-delivery of services.




https://sydneynorthhealthnetwork.org.au/programs/after-hours/

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