The future role and function of General Practice Units in the National Health Reform environment

D Jennifer AndersonDr David Isaac

Dr Ines RioDr Clare Seligmann

History GP Liaison in Victoria• Since the 1990. 2 major issues to start with– Declining communication b/w GPs and hospitals– Shared maternity care

• 1991: In 7 hospitals• 2000/2002: Hospital Demand Strategy - Hospital Admission Risk Program – A number estab with this $ to do work required– National email network– Informal support GPV

• 2006: – In 16 hospitals– Lenora Lippmann from GPV publishes many achievements– Auditor General’s report in 2006 noted dramatic increase in o/p

attendances: “up to 80% of patients… for review appts”– A number of recommendations areas GPL working on– DHS commissioned review of GP Liaison Program

Report findings• Funding varied: DH/Hospitals/Divisions• Consequently governance varied• Usually small team:

– all had a GP in them and most other staff clinical– GP 2-25 hours (average 10)

• High connections in hospitals • Highly valued by hospital/ GPs/Divisions/DH/PCPs

• High degree of consistency re. broad functions and significant range achievements– Information flow and processes– Relationships /communication b/w health services– Enhancing skills and capacity for GPs to care for patients in the

community who might otherwise require hospital care– Enhancing skills and capacity of health services staff to better

understand and respond to GPs

• Core functions nominated by GPL at that time:– Improve GP/patient access to health service– Liaison b/w health service and GP Divisions– Provide clinical advice– Contact point for consultation/liaison/advice for health

service in communication with GPs– Oversight shared maternity care– Design GP friendly hospital systems– Foster partnerships with community providers– Provide central point of contact for GPs

• Enormous range of specific activities according to need

Framework Victoria GP Liaison Program• 2007: DH acknowledgment

“Achieved significant changes in areas of information flow, processes of care and relationships and communications”Saw it as enabling arm of various DH policies

• Support program: Funded all metro programs to start with then extended to 2 large rural units with GPV advocacy

• Defined role/structure/strategic directions/reporting. Stipulated:

– In hospital– Team structure with a GP– High level executive support/reporting– Formal linkages with relevant Divisions– Participate in systematic planning at state & health service

level– Annual reporting DH

• Funded GPV:– Coordinate and support GPL Units– Assist with audits etc.– Provide/facilitate cpd– Facilitate strategic development, planning and reporting– (Also provided advocacy)

• 2010: Funding moved to general pot of outpatient funding

• 2011/2: MLs established. GPV defunded

• 2012: Few health services in the red― One of these has dismantled GPL― One has cut back to 1/2

What are some of the things we do• Core: – Monitor/report DC summary rates– GP details data improvement– Audits for info quality in and out: work on outcomes– Education hospital staff: needs GP– Cpd for GPs: sessions/upskilling outpatients– Take direct calls GPs: advice/complaints/service

utilisation/information: work on issues– Direct contact for hospital staff re GP issues– Strategies for patients to be linked to GPs– Work cross hospital develop info for GPs/HP– Involved in pushing electronic notification

Some specifics: RWHCurrent work includes:• Shared Maternity Care program

– Manage program– Cross health sector structures

• Breast cancer survivorship project • Redoing the website Health Professionals • Involved in development of parenting book• Dev policy on notification to AHPRA• Article b/w GP and 2 psychiatrists in press on perinatal mental

health identification and support• Triaged who gets an Dept US• Pre-referral guidelines

Some specifics: RCH

• Free community health provider education• Establishing tele-health as routine practice• Secure sending of outpatient letters• GP notification of receipt of referral letter• Pre referral guidelines • Clinical Services Directory• Top Tips

Some specifics: St Vincent's The standard, generic activities to simplify GP

navigation of the complex hospital system summarised in a “For GP” website.

Discharge summary completion program.(QI)- junior doc education- real-time online completion data- monthly email to Heads of Units

Secure Messaging - project now underway

Some specifics: St Vincent's (cont’d)

• Piloting a “VFSA” model for patients referred to Headache Clinic

• Outpatient Clinic improvement work –Referral guidelines, GP Outpatient referral audit, Vic Dept of Health Advisory Committee

• Leading the engagement of St V Execs to Medicare Locals.

History GP Liaison in QLD• 2008 – GPLO appointed with joint Division and QH

funding. Work with Aged referrals project in orthopaedics. – Subsequently this position continued to be funded

• 2009 – roll out of multiple aged referrals projects based on the Townsville model. E.g. hepatology project at PAH. These projects had GPLO as part of the project model

• GPs who have done these roles have often been asked to participate in other committees or advise on interface issues

GP Liaison now in QLD• 2010 – 2012 – localised roles funded a few

hours per month by Divisions/MLs to improve integration. No consistency

• Newman Government announces 20 GPLO positions in 20 biggest hospitals. – No funding details– No job description

• GPQ is working with QH on positions description and funding models for these

Core elements of success• Knowledge of health care delivery/clinical perspective

• Positioning in system• See the inside the hospital and outside the hospital• See what each think of each other and the “problems”

• Relationships • High level Relationships in hospital and community• Identify the champions/drivers and the blockers• Cross silo and vertical relationships in hospital an out:

executive/clinicians/IT/junior staff/managers/clerical staff/project staff: Boundary crossers

• Seen as a solver – go to person both sides

Core elements of success• AND Work on systems

• Work on core issues– Communication, quality, shared care, clinical handover,

gaps in knowledge etc.

• AND Being opportunistic:– Work with where there is momentum or concerns in

hospitals or with individuals– Scuttle your way into things– Identify synergies and work with them

• Being around

So…..GP Liaison & Medicare Locals?

Objectives of Medicare Locals

1. Identify the local health needs and develop locally focused and responsive services

2. Improve the patient journey through developing integrated and coordinated services

3. Provide support to clinicians and service providers to improve patient care

4. Facilitate the implementation and successful performance of primary health care initiatives & programs

5. Be efficient and accountable with strong governance and effective management

Performance Indicators: NHPA• 31 healthy communities reports: 17 hospital performance reports

• Safety, Quality/Access and Efficiency/Financial — Unplanned hospital readmission rates for patients following management

selected conditions (LHN)— Selected potentially avoidable hospitalisations (ML)— Rate community f/u w/i 7 days D/C from a psychiatric admission (LHN)— Measures of patient experience (ML and LHN)— Specialist service utilisation (ML)— Number women with at least one antenatal visit in 1st trimester (ML)— Primary care-type Emergency Department attendances (ML)

• Clearly need to work together – Info is reliable, valid, consistent– Addressing the indictors!

So?•GPL Unit and MLs goals are aligned•MLs/Hospitals need close strategic relationships to achieve •MLs/LHN will and should have high level CEO/executive relationships & planning•But MLs also need people that think the same way /similar objective working in the hospital system

– On the ground with departments– Being able to see all the hospital laundry– Opportunities/blockers/synergies

• Natural connection for that is GPL Units• MLs need them for meaningful hospital systems change

If GPL Units go – lots of the cross silo and vertical relationships will be lost to primary care and their functions will need to be replaced

• There are threats– Funding

• Whose role is it to fund?

– Not a clinical service (even though has a role in advice to keep people cared for by their GPs) – hard to measure impact

– Lack of coordinated research outputs from units

– Already seen the emergence of this in Victoria

Role Medicare Locals?

• Probable necessarily flexible

• Work together with GPL Units on NHPA Indicators and Healthy community report

• Aligned and complementary work plans

• MLs work with SBOs to provide:– Ongoing support and development/Advocacy– Strategic development– Reporting

• Work together with GPL Units to drive hospitals interface and integration work – Develop “minimum expectations”– Things better done in the community – often easier for GPL Units to

identify and MLs to drive this

Big one is the funding??

Health systems do not partner naturally

Improving the patient journey across health care sectors requires collaboration and is built on four main building blocks:• Relationship-building between hospitals and

GP/Primary Care• Complementary planning and implementation:

Incorporating the needs of the other in system design• Identifying system problems or road-blocks• Practical problem solving

Identify local health system needs and opportunities to address these & work on locally focused & responsive

responses

The GP Liaison program, although modest in size has been the “glue” and, in many cases the initiator, for many of the

collaborations across the hospital / Primary Care interface that underpin improvements to cross sector access, efficiency,

quality and the patient journey

GP Liaison Units are change agents – working for the needs of primary care and integrated care from within the hospital

Thankyou

Questions?