Sue meteyard

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.

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

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

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

Acute Care

Presentations to Robina and GCUH emergency departments

• 2012/13 - 125,730 • 2013/14 - 142,482

= 12 % increase

Partnering

Shared

Information &

Technology

Projects

GP Liaison

Positions

Shared Education &

Training

Agreements

& Committees

Joint Innovative

Project

&

Programs

Combined HHS /

Community funded positions

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

Current projects

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

determinantseHealth

Reducing unplanned hospital

presentations and /or admissions

Improved experience for persons with

COPD

Integrated Primary Health Care COPD Project

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

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

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%

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

• ↑ 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 GP’s via MO

• ↑ Understanding of what is happening with different disciplines

• Finalised format of the COPD service directory

• Knowledge about business practices (things aren’t always what they seem)

• Confirmation that existing internal processes and systems are being followed and are effective

Allied health achievements

• 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

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

Afterhours COPD Program GCML in collaboration with GCHSS Chronic Disease Wellness ProgramWill 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

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

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

Education & Training

Group• Spirometry• GCML & GCHHS combined opportunities• Motivational Interviewing • Regular networking forums

Individualised at practice/NGO level• eHealth• MBS item numbers• CQI processes

Lessons learnt

Leading Change

“Leading change requires not only a great idea but also the ability to mobilise individuals and organisations to embrace

change”

AcceptingThe

Challenge

AssessingOrganisational

Readiness

Maximising Support

Leading Transformation 2008 Advisory Board Company

• Assessment of organisational level of readiness

• Building trust and relationships

• Capacity building within the community

• Change management

• Sustainability

Lessons learnt

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