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Primary Health Networks Core FundingPrimary Health Networks After Hours Funding

Activity Work Plan 2016-2018 Annual Plan 2016-2018

Brisbane North PHN

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Table of ContentsIntroduction.......................................................................................................................................3

1 (a) Strategic Vision..........................................................................................................................5

1 (b) Planned activities funded by the flexible funding stream under the Schedule – Primary Health Networks Core Funding.....................................................................................................................6

2 (c) Planned core activities funded by the operational funding stream under the Schedule – Primary Health Networks Core Funding..........................................................................................14

2 (a) Strategic Vision for After Hours Funding.................................................................................18

2 (b) Planned activities funded by the Primary Health Network Schedule for After Hours Funding 20

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IntroductionOverview

The 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 right place at the right time.

Each PHN must make informed choices about how best to use its resources to achieve these objectives.

Together with the PHN Needs Assessment and the PHN Performance Framework, PHNs will outline activities and describe measurable performance indicators to provide the Australian Government and the Australian public with visibility as to the activities of each PHN.

This document, the Activity Work Plan, captures those activities.

This Activity Work Plan covers the period from 1 July 2016 to 30 June 2018. To assist with PHN planning, each activity nominated in this work plan can be proposed for a period of 12 months or 24 months. Regardless of the proposed duration for each activity, the Department of Health will still require the submission of a new or updated Activity Work Plan for 2017-18.

The Activity Work Plan template has the following parts:

1. The Core Funding Annual Plan 2016-2018 which will provide:a) The strategic vision of each PHN.b) A description of planned activities funded by the flexible funding stream under the

Schedule – Primary Health Networks Core Funding.c) A description of planned general practice support activities funded by the

operational funding stream under the Schedule – Primary Health Networks Core Funding.

2. The After Hours Primary Care Funding Annual Plan 2016-2017 which will provide:a) The strategic vision of each PHN for achieving the After Hours key objectives.b) A description of planned activities funded under the Schedule – Primary Health

Networks After Hours Primary Care Funding.

Annual Plan 2016-2018

Annual plans for 2016-2018 must:

provide a coherent guide for PHNs to demonstrate to their communities, general practices, health service organisations, state and territory health services and the Commonwealth Government, what the PHN is going to achieve (through performance indicator targets) and how the PHN plans to achieve these targets;

be developed in consultation with local communities, Clinical Councils, Community Advisory Committees, state/territory governments and Local Hospital Networks as appropriate; and

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articulate a set of activities that each PHN will undertake, using the PHN Needs Assessment as evidence, as well as identifying clear and measurable performance indicators and targets to demonstrate improvements.

Activity Planning

The PHN Needs Assessment will identify local priorities which in turn will inform and guide the activities nominated for action in the 2016-2018 Annual Plan. PHNs need to ensure the activities identified in the annual plan also correspond with the PHN Objectives; the actions identified in Section 1.2 of the PHN Programme Guidelines (p. 7); the PHN key priorities; and/or the national headline performance indicators.

PHNs are encouraged to consider opportunities for new models of care within the primary care system, such as the patient-centred care models and acute care collaborations. Consideration should be given to how the PHN plans to work together and potentially combine resources, with other private and public organisations to implement innovative service delivery and models of care. Development of care pathways will be paramount to streamlining patient care and improving the quality of care and health outcomes.

Measuring Improvements to the Health System

National headline performance indicators, as outlined in the PHN Performance Framework, represent the Australian Government’s national health priorities.

PHNs will identify local performance indicators to demonstrate improvements resulting from the activities they undertake. These will be reported through the six and twelve month reports and published as outlined in the PHN Performance Framework.

Activity Work Plan Reporting Period and Public Accessibility

The Activity Work Plan will cover the period 1 July 2016 to 30 June 2018.

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1 (a) Strategic VisionThrough the activities described in this Activity Work Plan, the Brisbane North PHN aims to increase the efficiency and effectiveness of medical services for patients, particularly those at risk of poor health outcomes; and improve coordination of care to ensure patients receive the right care in the right place at the right time by working towards our strategic vision and goals as documented below.

The Board of Brisbane North PHN endorsed our Strategic Plan 2016-2019 in March 2016. Our vision of a community where good health is available for everyone is underpinned by the following three strategic goals.

By working with others we will:

1. Re-orient the health system toward care in our community

Evidence shows that best population health outcomes are achieved in systems with strong investment in primary health care. Australians prefer to live healthy lives, in their own homes, as long as possible.

2. Achieve a health and community care system responsive to consumer need

Building responsive systems requires consumers who are health literate, channels through which needs can be expressed, and providers and funders who are willing and able to shape care delivery according to those expressed needs.

3. Target resources to best meet health and community care needs for our region

The PHN is committed to managing its resources to achieve maximum efficiency and effectiveness. Alone, the PHN’s resources are insufficient to meet the needs of our region, leading the PHN to adopt a collective impact approach, influencing others to work in a more coordinated fashion on common goals. As a commissioning agency, the PHN targets resources in accordance with community-led plans to ensure the most equitable delivery of services.

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1 (b) Planned activities funded by the flexible funding stream under the Schedule – Primary Health Networks Core Funding

Proposed Activities

Priority Area Health promotion (1)

Activity Title / Reference NP 1 Promoting a healthier Brisbane North

Description of Activity

Evidence shows that identifying people early who are at risk of developing chronic diseases and educating those with a chronic disease in managing their health will lead to better health outcomes for Brisbane North PHN region.

The PHN will undertake two key activities which aim to improve the health of the population:

1. Health Navigator: is an evidence-based risk assessment app that assesses an individual’s risk of cardiovascular disease, diabetes and kidney disease and connects them with healthy lifestyle programs. The PHN aims to increase the effectiveness of the app by supporting GPs and allied health professionals to use it with at risk patients and improve the referral pathways to healthy lifestyle programs.

2. Immunisation: the PHN will work in partnership with the Metro North Hospital and Health Service Public Health Unit to support general practices to improve immunisation rates of children. The PHN will also run a health promotion campaign targeted at areas with low immunisation rates.

These activities align with the PHN objective of Increasing the efficiency and effectiveness of medical services for patients, particularly those at risk of poor health outcomes.

Collaboration These two activities will be jointly implemented with stakeholders and we will continue to build partnerships with the Metro North Hospital and Health Service, particularly the Public Health Unit around immunisation.

Other stakeholders that will be involved in the Health Navigator activity include:

Heart Foundation Stroke Foundation Kidney Health Australia Diabetes Queensland

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Ethnic Communities Council of Queensland Institute for Urban Indigenous Health Multicultural Queensland (MDA) Moreton Bay Regional Council.

Indigenous Specific No

Duration 2016 - 2018

Coverage Entire PHN region

Commissioning approach

These services will be commissioned in line with Brisbane North PHN’s Commissioning Framework.

Following competitive dialogue and further co-design work, our procurement strategy – open, select, direct negotiation or a combination of these – will be determined

Our approach to monitoring and evaluating contracted services varies depending on the size of the contract and the operational funds available. Program staff meet regularly with funded agencies, and our client relationship management system provides funded agencies with reminders of deliverables due. Our Contract Management Module tracks payments and achievement of milestones, raising red flags when deliverables are not produced on time. Service data is usually required quarterly, financial and activity reporting is required six and twelve monthly.

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http://www.brisbanenorthphn.org.au/page/about/commissioning/

Proposed Activities

Priority Area Moreton Bay North (2)

Activity Title / Reference NP 2 Addressing the health and wellbeing of vulnerable groups in the Moreton Bay North sub-region


Research has shown that residents in Moreton Bay North face economic and social conditions that result in poorer health for its population. People in this sub region have the poorest health status and highest health risk factors of any PHN sub region. Yet it has the lowest provision of health services and health workforce.

The PHN will undertake two key activities which aim to improve the health of the Moreton Bay North population:

1. Outreach health care to vulnerable children

The PHN will continue our partnership with Act 4 Kids to improve access to allied health services in high needs areas. Act for Kids will provide on-site allied health services at schools in the Moreton Bay North region.

2. Cross-sectoral collaboration

Brisbane North PHN has identified the need to develop a regional plan to form a collective impact project addressing the health needs of the Moreton Bay North region. The regional plan is aimed at identifying stakeholders (both private, public and non-government agencies) who we can work in partnership with improve long term health outcomes for the PHN:

adults at-risk of or living with chronic disease children at risk of poor health outcomes.

The regional plan will then identify agreed priorities for improvement. It will also detail indicators to measure achievement of change in relation to each priority and identify activities to address the identified priorities.

Further details of this project will be detailed in the regional plan, which will be submitted to the Department as part of our six month report.

These activities align with the PHN objective of increasing the efficiency and effectiveness of medical services for patients, particularly those at risk of poor health outcomes.

Collaboration The regional plan will be undertaken in collaboration with other stakeholders including:

Metro North Hospital and Health Service Moreton Bay Regional Council

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local general practitioners and allied health service providers local NGOs local Aboriginal Medical Services local community groups Queensland Health and other state government departments.

The role of these stakeholders will be to co-design and inform our regional plan to ensure a coordinated approach and to avoid duplication.



Coverage Moreton Bay – North (statistical area 4)


These services will be procured through a combination of direct approach to existing provides (Outreach health care to vulnerable children) and co-design/competitive dialogue (Cross-sectoral collaboration).


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Proposed Activities

Priority Area Potentially preventable hospitalisations (PPH) (3)

Activity Title / Reference NP 3 Keeping people healthy and in the community

Description of Activity The PHN will undertake a range of activities across the entire health care sector to ensure patients receive the right care in the right place at the right time.

The PHN will undertake five activities which aim to reduce the rate of potentially preventable hospitalisations:

1. Innovative models to support Residential Aged Care Facilities (RACFs): aims to reduce unnecessary admissions to hospitals. There is a particular focus on residential aged care facilities (RACFs), with the aim reducing the rate of potentially preventable hospitalisations by improving co-ordination between RACFs, primary care, community care and our local Hospital and Health Service (HHS). The PHN will support better communication between RACFs, general practitioners (GPs), the Ambulance Service and hospital Emergency Departments (ED). It will also support better connections between RACFs and primary care to improve service delivery models for palliative care patients, including consideration of models for nurse practitioners and geriatric outreach programs.

2. Pathways Program: aims to improve the continuity of patient care by encouraging the uptake of patient care maps for a range of priority clinical areas and services within the North Brisbane region. Over the next two years, the Pathways Program will continue to work closely with the HHS and local primary care service providers to prioritise pathways that will have the highest impact on preventable hospital admissions.

3. Health Workforce Innovation: involves up-skilling administrative staff in general practice to undertake both administrative and clinical assisting roles. This boosts the general practice workforce by freeing up practice nurses and GPs to use their higher-level skills in complex patient care to prevent potentially preventable hospital admissions.

4. Service Navigation: this service was developed in response to community need for health service navigation information that will lead to people receiving the right care in the right place at the right time.

5. Health Data Project: the aim of this activity is to improve the collection and use of primary care data through general practices and PHN systems. This will support general practices to make use of their practice data to better manage patient populations leading to more appropriate use of hospital services.

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These activities align the PHN objectives of:

increasing the efficiency and effectiveness of medical services for patients, particularly those at risk of poor health outcomes

improving coordination of care to ensure patients receive the right care in the right place at the right time.

Collaboration

These activities will be jointly implemented with stakeholders. Preliminary stakeholders identified include:

residential aged care facilities operating in the PHN region Metro North Hospital and Health Service general practices and allied health providers Queensland Ambulance Service community care providers.



Coverage Entire PHN region


These services will be procured through a combination of direct delivery (health workforce innovations and pathways program), approach to market (health data project) and co-design/competitive dialogue (innovative models to support RACFs and Service Navigation).


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Proposed Activities

Priority Area Aboriginal and Torres Strait Islander health (4)

Activity Title / Reference NP 4 Improving health outcomes and engagement for Aboriginal and Torres Strait Islander communities


Brisbane North PHN has a large Aboriginal and Torres Strait Islander population who suffer significant health inequalities across a number of indicators, resulting in poorer life expectancy than the population as a whole.

The PHN will undertake three key activities which aim to improve health outcomes for the Aboriginal and Torres Strait Islander community.

1. Reduce smoking rates in pregnant Aboriginal and Torres Strait Islander women

Our evidence shows that Aboriginal and Torres Strait Islander mothers have a significantly higher rate of smoking during pregnancy. The PHN intends to commission culturally appropriate and locally tailored awareness and education campaigns to decrease the rates of smoking, particularly maternal smoking, among Aboriginal and Torres Strait Islander people.

2. Patient satisfaction monitoring

The PHN will support healthcare providers to implement the Patient Opinion feedback tool to better engage with Aboriginal and Torres Strait Islander patients to understand the challenges and build capacity in health care organisations to better meet the needs of Aboriginal and Torres Strait Islander people.

3. Aboriginal and Torres Strait Islander community engagement

The PHN commissions the Institute for Urban and Indigenous Health (IUIH) to provide services for this community. There is a need for the PHN to deepen and broaden its engagement with Aboriginal and Torres Strait Islander stakeholders, including the IUIH.

As a result, the PHN will develop a regional plan that details strategies to engage with Aboriginal and Torres Strait Islander communities to facilitate improved health service co-design and creation in our region. The PHN will engage with Aboriginal and Torres Strait Islander stakeholders in developing this plan.

These activities align with the PHN objective of increasing the efficiency and effectiveness of medical services for patients, particularly those at risk of poor health outcomes.

Collaboration This activity will be jointly implemented with stakeholders and we have preliminary identified in collaboration with participants at our two co-design workshops:

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Metro North Hospital and Health Service (including: Aboriginal and Torres Strait Islander Health Unit, Public Health Unit and Planning and Strategy team)

Institute for Urban Indigenous Health (IUIH) Aboriginal Medical Centres (including Community Liaison Officers) Reconciliation Queensland Incorporated Aboriginal and Torres Strait Islanders elders Queensland Islander and Aboriginal Health Commission local elder groups.

These organisations and people will help develop the plan for engagement with the Aboriginal and Torres Strait Islander community. The outcomes highlighted in this document will also help to inform our campaigns in reducing smoking rates in Aboriginal and Torres Strait Islander women.

Indigenous Specific Yes

Duration 2016 – 2018

Coverage Entire PHN region but in the future it may focus more specifically in the area of Moreton Bay – North (statistical area 4) as it has the largest Aboriginal and Torres Strait Islander population.


These services will be procured through a combination of direct approach to existing provides (patient satisfaction monitoring) and co-design/competitive dialogue (reduced smoking rates and Aboriginal and Torres Strait Islander engagement).


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2 (c) Planned core activities funded by the operational funding stream under the Schedule – Primary Health Networks Core Funding

Proposed general practice support activities

Activity Title / Reference OP 1 Quality in general practice


This activity aims to support general practice staff and clinicians to provide high quality care for their patients.

Support will include but not be limited to:

support for practices to achieve and maintain accreditation as a general practice; support practices to maintain high quality clinical data; facilitation of data analysis to support quality improvement through clinical auditing; support for general practices to use patient feedback to improve quality of practice; provision of and information regarding access to appropriate education both clinical and administrative to

support quality in general practice, and provision of resources both developed by the PHN and sourced from other relevant agencies.

This activity will assist the PHN in increasing the efficiency and effectiveness of medical services for patients, particularly those at risk of poor health outcomes.

Collaboration The PHN will collaborate with various stakeholders such as general practice education providers and accrediting bodies to ensure the support provided to general practices is appropriate, relevant and up to date.


Coverage Whole of region

Expected Outcome

It is expected that by undertaking this activity the following outcomes will be achieved:

practices that are currently accredited will maintain their accreditation there will be an increase in the number of new and unaccredited practices supported to achieve accreditation there will be an increase in the number of practices participating in data quality improvement activities.

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Activity Title / Reference OP 2 eHealth support


This activity aims to assist general practices to make the best use of available eHealth technology to provide efficient and effective medical services for their patients.

Assistance will include but not be limited to:

assistance to achieve and maintain digital health compliance, including meaningful use of the MyHealth record assistance to set up and make the best use of secure messaging to ensure clinical information is shared

appropriately, efficiently and accurately between care providers assistance in the use of eReferral and eDischarge to ensure clinical handover takes place as efficiently and safely

as possible support for the use of telehealth where appropriate to provide improved access to appropriate care for patients

who find it challenging to travel to appointments.

This activity will assist the PHN in increasing the efficiency and effectiveness of medical services for patients, particularly those at risk of poor health outcomes as well as improving coordination of care to ensure patients receive the right care in the right place at the right time.

CollaborationThe PHN will collaborate with various stakeholders such as Secure messaging providers, telehealth supported technology vendors and the Metro North HHS to ensure the best support is provided to general practices for them to take advantage of eHealth technology and systems.



Expected Outcome


All accredited practices will be eligible to receive the Digital Health Practice Incentive Program payment. The PHN will increase number of practices using secure messaging for eReferral and eDischarge.

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Activity Title / Reference OP 3 Workforce support


This activity aims to identify and address workforce needs in particular sub regions or professional cohorts to ensure sustainable general practice provision across the region.

Activities will include but not be limited to:

continued facilitation of the Certificate IV in Medical Practice Assisting facilitation of professional development including assisting with clinical audits to support continuous professional

development provision of assistance with general practitioner recruitment in areas of high need when required promotion of clinical pathways tools especially for overseas trained doctors and registrars to ensure best practice

clinical pathways are available and local referral information is at hand when required.


Collaboration The PHN will collaborate with various stakeholders such as education providers, the RACGP in realtion to conducting clinical audits and the Metro North HHS in relation to the development of best practice and localised clinical pathways.



Expected Outcome


An increase in number of medical reception staff upgrading their skills by undertaking a Cert. IV in Medical Practice Assisting and therefore creating increased clinical capacity in the practice team.

An increase in number of clinical audits completed, resulting in improved efficiency and effectiveness of clinical and non-clinical procedures in the practice.

An increase in the number of GPs registered to access health pathways, resulting in best practice primary health care a reduction in inappropriate referrals to the acute sector.

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Activity Title / Reference OP 4 Primary health care integration


This activity aims to facilitate collaboration of general practice with other primary health care providers such as allied health and pharmacy to encourage a holistic approach to multidisciplinary patient care.

Support will include but not be limited to:

facilitation and support for multidisciplinary professional development activities facilitation of the analysis of general practice data in relation to patient referrals to allied health services support for improved communication between general practice and allied health practices to undertake effective

clinical handover using secure messaging support for allied health and pharmacy to access digital health systems and tools such as MyHealth record provide up to date and easily accessible service navigation for health professionals through the PHN Service

Navigator hotline to ensure GPs and allied health professionals have easy access to information regarding local services for their patients.


Collaboration The PHN will collaborate with all types primary health care providers to encourage multidisciplinary patient care.



Expected Outcome


General practices will more aware of allied health and pharmacy services within their local region An increased number of allied health providers will be using secure messaging to communicate clinical

information with general practice. An increased number of allied health practices and pharmacies Digital Health ready> Current community and allied health service information will be readily available to general practice and other

service providers.

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2 (a) Strategic Vision for After Hours FundingData from the Health Needs Assessment shows high levels of demand for after-hours service across general practice deputising services, hospital emergency departments and 13 HEALTH services, indicating there is a health need for after-hours services in the region.

Through the activities described in the After Hours section of the Activity Work Plan, the Brisbane North PHN aims to increase the efficiency and effectiveness of After Hours Primary Health Care for patients, particularly those with limited access to Health Services and improve access to After Hours Primary Health Care through effective planning, coordination and support for population based After Hours Primary Health Care, by working towards our strategic vision and goals as documented below.

The Board of Brisbane North PHN endorsed our Strategic Plan 2016-2019 in March 2016. Our vision of a community where good health is available for everyone is underpinned by the following three strategic goals.

By working with others we will:

1. Re-orient the health system toward care in our community

Evidence shows that best population health outcomes are achieved in systems with strong investment in primary health care. Australians prefer to live healthy lives, in their own homes, as long as possible.

The PHN aims to increase capacity in the primary health care sector to ensure improved service delivery to vulnerable groups, including specific locations and populations groups, where after hours services currently do not meet needs. Through the identification of appropriate care pathways and support systems to access these pathways, the PHN aims to support the delivery of care in the community rather than the acute hospital setting, where appropriate.

2. Achieve a health and community care system responsive to consumer need

Building responsive systems requires consumers who are health literate, channels through which needs can be expressed, and providers and funders who are willing and able to shape care delivery according to those expressed needs.

The PHN aims to enhance health literacy by improving awareness of the options for accessing after hours health services and thereby helping people make informed choices when accessing services.

3. Target resources to best meet health and community care needs for our region

The PHN is committed to managing its resources to achieve maximum efficiency and effectiveness. Alone, the PHN’s resources are insufficient to meet the needs of our region, leading the PHN to adopt a collective impact approach, influencing others to work in a more coordinated fashion on common goals. As a commissioning agency, the PHN targets resources in accordance with community-led plans to ensure the most equitable delivery of services.

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By providing training to after hours doctors to improve service delivery in aged care facilities and palliative care situations, the PHN aims to influence the after hours deputising services to work in a more coordinated fashion, making the best use of primary care after hours resources.

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2 (b) Planned activities funded by the Primary Health Network Schedule for After Hours Funding

Proposed Activities

Priority Area After-hours (5)

Activity Title / Reference NP 5.1 After-hours: Outreach to homeless and vulnerable population groups

Description of Activity Brisbane North PHN aims to continue to provide services to homeless and vulnerable population groups. This will be done through the continuation of subcontracting local agencies to provide after hours clinical services and care coordination, including connection to mainstream primary care services, to homeless and vulnerable population groups across the region.

1. Micah Projects will be subcontracted to deliver nursing services as part of a homeless outreach service, with a focus on the Brisbane City area. Previously funded by the Medicare Local and Brisbane North PHN, evaluations demonstrate significant reduction in after hours burden on the hospital system.

2. Queensland Injectors Health Network (QuIHN) will be subcontracted to provide outreach health services to homeless and vulnerably housed people, with a focus on the Moreton Bay area. This project, previously funded by the Medicare Local and Brisbane North PHN, uses the Micah Projects model.

Other projects which the PHN will be continuing include:

Refugee health: the PHN will continue to collaborate with the Greater Brisbane Refugee Partnership Advisory Committee to improve access to primary health care for refugees. Activities will include joint planning, service development and commissioning of services, coordination of care for refugees, providing support for training and resources for primary care providers and participating in data collection and analysis.

Improved access to primary care sexual health services: The PHN will improve access to primary care based sexual health services in the region.

The PHN will support non-government organisations (NGOs) to establish primary care capacity for hard to reach groups including in the after-hours. This will include strengthening links between NGOs and primary care and providing practise support and advice to NGOs.

Our Health Needs Assessment identified that people from culturally and linguistically diverse backgrounds (like refugees) often face many barriers in accessing primary healthcare including service navigation and health literacy. These barriers may result in poorer health outcomes and put them at a greater risk of mismanaging their medication and condition. By

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continuing to collaborate with the Greater Brisbane Refugee Partnership Advisory Committee, we aim to benefit the healthcare system by commissioning services that provide better coordination of care for refugees particularly in a primary care setting. This is to avoid people from inappropriately accessing secondary care during after hours.

Following changes to the Queensland sexual health service delivery options, Brisbane North PHN has worked with NGOs and primary care providers to support their increased knowledge and capacity to fill these gaps. This ongoing work includes the delivery of after-hours sexual health services from primary care providers in a number of locations.

This aligns with the PHN objective of implementing innovative and locally-tailored solutions for after hours services, based on community need.

Collaboration

The PHN will continue to collaborate and partner with Micah and Queensland Injectors Health Network (QuIHN).

The two subcontracted agencies involved in service delivery for this project operate an outreach model, with nursing and other staff able to travel to see individuals in a place of convenience. For instance, the subcontracted agencies may see patients in their home, in a location of short-term accommodation, or whilst the individual is accessing another service such as a food van.

1. Micah Projects will provide services to the Brisbane City area via an outreach model. While previous service provision data indicates the most common source of referral is the individual patient, referrals are also received from social service providers (e.g. domestic violence agencies, housing agencies) and hospitals.

2. QuIHN will provide services to the Moreton Bay area via an outreach model. Service provision under this project was initiated in 2014-15 and occurred alongside other existing services such as food vans and community events. Referrals for this service are either from the individual or a family member.

The role of all these organisations is to engage and inform the PHN in delivering appropriate after-hours services for people who are often hard to reach and are disengaged with current health services.




Commissioning approach These services will be procured through a combination of direct approach to existing providers (homelessness, vulnerable populations, refugee health and sexual health) and co-design/competitive dialogue (establishment of primary care capacity).

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Proposed Activities


Activity Title / Reference NP 5.2 After-hours: Aged and palliative care services


Brisbane North PHN will work with Residential Aged Care Facilities (RACFs) to address after hours issues, to improve the capacity of RACFs to work collaboratively with primary care providers to develop and implement local models of care that reduce unnecessary hospital presentations and improve the patient experience.

Evidence from across the Brisbane North region has identified four key concerns:

1. Training Needs: to build on the current education program and integration of palliative care services across the acute, primary and community sector. Feedback from key stakeholders has identified that further intervention is required to reduce inappropriate presentations to Emergency Departments; and improve the patient experience.

2. Home Visiting Medical Services: stakeholder feedback informs that access to home medical services - in-hours - for patients who require to be managed in their residence is extremely patchy. This results in delays in best management of patient symptoms causing distress to patients and carers and after-hours presentation at ED.

3. Mobile x-ray: a lack of access to mobile x-ray services means that patients are transported from RACF to hospital whenever they require an x-ray.

4. Palliative care coordination: the PHN will continue to support improved community palliative care through collaborative planning, capability and capacity development, and networking amongst interested stakeholders. .

The following activities will address these concerns:

1. Training Needs: the development of training models for After Hours GP services will be provided to relevant health professionals in the Brisbane North region.

2. Home Visiting Medical Services: to explore models of care that enable a mobile workforce to ensure patients at the end stage of life are able to access appropriate medical management in their place of residence.

3. Mobile x-ray: the PHN will commission a mobile X-ray service and provide funds to cover aspects of this service that are not covered by MBS rebates.


Collaboration Brisbane North PHN will broadly collaborate with:

residential aged care facilities (RACFs)

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palliative care providers Metro North Hospital and Health Service (MNHHS) (including the Emergency Departments) Queensland Ambulance Service (QAS) after hours GP services.

1. Training needs: will be led by the PHN and will be implemented through a multiagency approach bringing together key stakeholders (after-hours GP services, QAS, MNHHS, and aged care and palliative care providers). This project will build on the innovated training model developed for after hours GP services that aligns with and enhances QAS staff training to increase their knowledge and understanding of palliative care needs in the community. The identified systems and processes of the Brisbane North palliative care services. Brisbane North PHN will seek to engage a suitably qualified contractor/consultant to continue to review and develop the necessary training and resources to deliver this training to identified home visiting Health professionals including after hours GP services.

2. Mobile x-ray: services will be delivered by an existing provider equipped to deliver outreach services. Existing commissioning process to ensure suitable provider/s are contracted to deliver this service. This project will be piloted within the Chermside area, where there is a concentration of RACFs. Brisbane North PHN will work closely with RACFs and mobile x-ray provider/s to ensure referral and service delivery processes are resulting in efficient and effective service delivery. Following this pilot period, it is expected the program will be delivered across the entire PHN catchment.





These services will be procured through a combination of direct approach to existing providers (training needs), approach to market (home visiting medical services and mobile x-ray) and co-design/competitive dialogue (palliative care co-ordination).


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Proposed Activities

Priority Area After–hours (5)

Activity Title / Reference NP 5.3 After-hours: Management of frequent emergency department (ED) attenders


Work with key local stakeholders to improve patient outcomes by providing viable and sustainable alternatives in health care compared with frequently accessing ED. This will involve collaborative work between service providers to deliver a coordinated community and primary care response, with a focus on improving patient health literacy on the appropriate health service to access in the after-hours period.

Collaborative work with Metro North Hospital and Health Service (MNHHS) has identified shared difficulties across the five public hospitals within the Brisbane North PHN catchment with regards to frequent ED presenters.

In 2015-16, Brisbane North PHN worked in partnership with key community agencies and MNHHS services to develop and implement a model of sustainable management for frequent attenders. To date, we have worked with MNHHS to identify the target group, early deployment and intervention by community services, established cross-sector, cross-specialty case conferencing protocols and outcome monitoring processes. In 2016-17 this work will continue and Brisbane North PHN will subcontract two organisations to provide specialist community support to people who frequently present to EDs. Micah Projects and Footprints in Brisbane will provide a 7-day response–including after hours services–to referrals from the HHS, including nursing and other support.


Collaboration

Brisbane North PHN will work in partnership with:

Metro North Hospital and Health Service Micah Projects Footprints.

These organisations will provide specialist community support to people who frequently present to emergency department.




Commissioning approach These services will be procured through direct approach to existing providers.

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Proposed Activities


Activity Title / Reference NP 5.4 After-hours: Integrated community education campaign


Brisbane North PHN will continue its integrated community education campaign to improve awareness of the options for accessing after-hours services and help people make appropriate informed choices when accessing services. The campaign will focus on people inappropriately accessing emergency departments and also target populations who may have difficulty in accessing appropriate after-hours services.

Specifically, this project will involve:

1. Development of an integrated community education campaign, bringing together key stakeholders including general practitioners (GPs), pharmacies, Australian Medical Association Queensland (AMAQ), the Pharmacy Guild, Queensland Health, and Metro North HHS.

2. Implementation of an integrated community education campaign using traditional media, online and face-to-face delivery, with a focus on health literacy principles to ensure the information is accessible to vulnerable population groups.

Our evidence shows that there are specific population groups who are more likely to inappropriately access ED services after hours:

young people (typically aged 20 – 35 years) parents with young children.

Based on this, the campaign will target these population groups and more broadly will educate people on after-hour services other than the emergency department of a hospital.


Collaboration This work builds upon existing relationships and partnerships including:

Queensland Health Metro North Hospital and Health Service general practitioners working in our region pharmacists working in our region

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Australian Medical Association Queensland Royal Australian College of General Practitioners.

The role of these organisations is to inform our campaigns when targeting people to improve their awareness of appropriate after hours services.





These services will be procured through an approach to market.


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