1. Linking Medicare Locals & Hospitals: How these services are working together to maintain the health and wellbeing of Gold Coast residents 24 July 2014 Medicare Locals gratefully acknowledge the financial and other support from the Australian Government Department of Health.

2. Today Setting the Scene The role of Medicare Locals Partnering Leadership Current Projects Integrated Primary Health Care COPD project Care coordination Afterhours COPD project Transitional Lungs in Action Lessons learnt 3. Role of Medicare Locals Improve coordination and integration of primary health care in local communities, address service gaps, and make it easier for patients to navigate their local health care system Horvath Report March 2014 4. A Day on the Gold Coast 576 people are admitted to hospital - 218 are preventable 93 women screened for breast cancer 41 people see a diabetic educator or a dietician The population increases by 30 people 4 to 8 12-25 year olds seek mental health services 7098 people see a GP 108 people see a psychologist Primary Care 5. Acute Care Presentations to Robina and GCUH emergency departments 2012/13 - 125,730 2013/14 - 142,482 = 12 % increase 6. Partnering Shared Information & Technology Projects GP Liaison Positions Shared Education & Training Agreements & Committees Joint Innovative Project & Programs Combined HHS / Community funded positions 7. Leadership Joint participation in population health needs identification and service planning GCML / GCHHS Executive Steering Committee Engages other leading primary care organisations on the Gold Coast Primary Health Care Protocol Leads development and implementation of evidence based innovative models of care Gold Coast Lead Clinician Group Plays a lead role in improving and integrating health care through quality general practice General Practice Gold Coast Voluntary collaboration between government and non government sectors to share information and improve coordination Primary Care Partnership Council 8. Current projects 9. Aim: To develop an agreed service model for best practice COPD management From prevention through to end stage management Develop pathways to support communication & exacerbations Increased MDT communication & Improved Care Coordination Increased COPD screening Health literacy and other social determinants eHealth Reducing unplanned hospital presentations and /or admissions Improved experience for persons with COPD Integrated Primary Health Care COPD Project 10. The approach Practice Support Prevention Health literacy eHealth MDT communications Pathways Allied Health eHealth MDT communication Pathways service directory Care Coordination Care Coordination Health literacy MDT communication eHealth Improved patient experience GCHHS Complex management Reducing unplanned hospital presentations and/or admissions eHealth MDT Communication Education and Training 11. Practice support October 2013 June 2014 5 practices engaged Variations in practice size and staffing Developed a minimum data set looking at organisational and process data Installation/training for PenCAT (data extraction tool) Monthly CQI visits 12. Practice support achievements Baseline Current % Change (n=40) (n=202) Spirometry recorded 19% 39% 20% Current smokers 21% 28% 7% Smoking status NOT recorded 17% 6% 11% Fluvax vaccination recorded (within last 12 months) 28% 54% 26% Pneumococcal vaccination recorded (within last 5 years) 14% 22% 8% GPMP 28% 49% 21% TCA 31% 48% 15% 13. Allied health November 2013 June 2014 16 practices engaged Solo, part-time practitioners through to large multidisciplinary practices across multiple sites Private and non-government Physiotherapy, Exercise Physiology, Occupational Therapy, Dietetics, Psychology, Pharmacy, Social Work and Speech Pathology Developed a minimum data set looking at organisational and process data Installation of Medical Objects 14. Use of Medical Objects for communication with GPs including acceptance, completion of initial and final reports in a timely manner Patients continuing treatment Amount of paperwork received at time of referral Two-way communication with GPs via MO Understanding of what is happening with different disciplines Finalised format of the COPD service directory Knowledge about business practices (things arent always what they seem) Confirmation that existing internal processes and systems are being followed and are effective Allied health achievements 15. Based on Metro North Brisbane Team Care Coordination Program for Medicare Locals primarily providing a navigation function Development of tools and processes to support communication 21 referrals received from Jan 2014 to date from: 5 engaged COPD practices (13) GCHHS Chronic Disease Wellness Program (8) Patients can be seen at home or in the practice setting Case conference with GP and other service providers when needs are out of scope Access to brokerage funds if required Reviewing the patient experience to feedback into pathway development Care coordination 16. General Practice Access to eHealth PCeHR registrations Utilisation of MO following development of templates COPD Care plan, Case conference and COPD Action Plan, HMR Use of GPMP Case Conference attendance (4) GCHHS Referrals expected from GCHHS to support the Chronic Disease Wellness Strategy Care Coordination achievements 17. Afterhours COPD Program GCML in collaboration with GCHSS Chronic Disease Wellness Program Will provision of after hours nursing, physiotherapy, personal care and equipment result in reduced admissions for clients with 2 admissions for COPD in the previous year? Wellness Support Strategy COPD proactive care & monitoring- however no after hours response in event of after hours exacerbations Hospital presentation relating to after hours exacerbation-anxiety, lack of timely nursing review/chest physiotherapy, oxygen, equipment Extended hospital stay while awaiting oxygen, support at home, no supported transport home and resettling Partnership with GCML, participation in tendering process Service Agreement with Blue Care Procedure developed with endorsement of acute and specialist team Up skilling of Blue Care staff in COPD management Emergency Department based staff and Discharge Planners case find eligible clients Timely access to comprehensive community COPD assessments; feedback loop between acute sector and NGO Evaluation After Hours COPD Project Commenced January 2014 Opportunities from NGO re monitoring of clients who have stayed well with WSS 18. Afterhours COPD Program achievements Current activity 17 referrals received for 7 COPD patients All referrals were for physiotherapy Unit cost per visit = $1100 No adverse outcomes Planned modifications to the program Increase support during peak times Extend service to less complex respiratory patients Ongoing education and communication of successes to build trust from acute sector for NGO involvement in patient care 19. Transitional Lungs in Action GCML funding provided to GCHHS in the form of an Innovation Grant, January 2014 Investigates the benefits and feasibility of introducing an additional program to patients at risk of discontinuing their treatment and self-management of COPD Program builds on knowledge and skills learnt in Pulmonary Rehabilitation through structured and non- medically supervised exercise classes with the view to building the patients confidence to transition into a community based program 20. Education & Training Group Spirometry GCML & GCHHS combined opportunities Motivational Interviewing Regular networking forums Individualised at practice/NGO level eHealth MBS item numbers CQI processes 21. Lessons learnt 22. Leading Change Leading change requires not only a great idea but also the ability to mobilise individuals and organisations to embrace change Accepting The Challenge Assessing Organisational Readiness Maximising Support Leading Transformation 2008 Advisory Board Company 23. Assessment of organisational level of readiness Building trust and relationships Capacity building within the community Change management Sustainability Lessons learnt 24. Acknowledgements GCML Andrea Sanders Integrated Care Program Manager Chris Ash Care Coordinator (COPD) Emma Briskey Allied Health Project Officer Fiona Hill Primary Health Care Support Officer Kathleen Kojima - Primary Health Care Support Officer Bev Korn Primary Health Care Support Program Manager Sandra McElroy Administration Support Shane Patterson Project Officer Maureen Penwright - Primary Health Care Support Officer GCHHS Judith Murrells CNC Respiratory Services Rose Costa Acting Coordinator, Chronic Disease Wellness Program