5 minute read
Health System Integration and Coordination (GEN 6
Over the last 20 years, there have been a number of attempts to lessen the fragmentation within the Australian health system with varied outcomes. As we move further into the technological age, some system boundaries are gradually shifting, but barriers continue to ensure that critical areas are not quite connected. As the backbone support organisation, CSAPHN in partnership with other key players, will provide resources and expertise to enable collective initiatives to succeed, thus improving system integration and the patient journey.
Advertisement
Identified Need Key Issue Description of Evidence Health Systems integration
and coordination –outcome of service needs analysis Referral pathways can be unclear. Practitioners may not be aware of all referral options.
Having to travel long distances to access multiple consultations/treatment, patients are often unable to coordinate appointments and/or face hardship in affording transport, accommodation, absence from home, etc.
Gaps identified in discharge planning.
Patients with complex conditions require care input from multiple practitioners, which is currently difficult to coordinate effectively in many regions.
Palliative care ∙ Palliative care options are perceived to be limited in smaller communities ∙ Limited information available about current services and care pathways throughout the region. ∙ Issue of importance in priority matrix ∙ Key theme in ML and PHN stakeholder consultations ∙ Issue highlighted by the six regional Local Health Networks
Priority Health Systems integration and coordination (GEN – 6)
opportunities, priorities and options
Possible Options
1. Engage with all providers to develop the capacity of the region to: ∙ engage care coordinators in routine activities ∙ identify opportunities and create strategies to implement consistent coordinated team care. ∙ Patients will be able to access specialist and allied health consultations as close as possible to their place of residence as evidenced by increased uptake of coordinated care services. ∙ CSAPHN
Expected Outcome Potential Lead
Priority Health Systems integration and coordination (GEN – 6)
opportunities, priorities and options - continued
Possible Options
2. Promotion and facilitation of the Patient Centred
Medical Homes. ∙ Review and redesign of integrated health systems ∙ Work with and drive inter-sectoral partners supported by research to develop a primary health service delineation model for rural SA ∙ Identifying and seeking to rectify inequalities in services delivered regionally. 3. Use existing resources, redirected to engagement of care coordinators in various employment models.
Expected Outcome
∙ Mapping, collaboration and education activities resulting in real restructuring of local activities to include models of coordinated care in service delivery.
∙ Commissioned activities reflect the placement of care coordination in local models of connected care.
4. Implementation of a project which enables shared clinical reviews that are evidenced to be a useful tool in managing complex conditions, particularly for people who blur the eligibility lines across services and whose needs vary from time-to-time. 5. Multi-party conferencing to enable activities such as case conferencing with health professionals within SA
Health. ∙ Shared clinical reviews reported to be occurring in sentinel sites and expanding.
∙ Shared clinical reviews reported to be occurring in sentinel sites and expanding.
6. Implementation and promotion of My Health Record. ∙ Better coordinated care through use of shared electronic records.
7. Investigate potential models for support to or coordination of activity to assist the management of high or frequent users of the health system, as an avenue for hospital avoidance and support for patients with complex needs.
8. Stakeholder engagement program – Primary Health Care
Nurse Networks and Clinical Councils; provide access to relevant resources, training and guidance on MBS item use including care plans and practice nurse support chronic disease of self-management. ∙ Partnership with LHN and other providers achieved, focussing on better data intelligence of needs and sentinel activity achieved and implementation of alternative service provisions out of hours.
∙ Resources provided consistently across the region with evidence of uptake and use identified.
Potential Lead
∙ CSAPHN and other public and private providers
∙ CSAPHN and other public and private providers
∙ CSAPHN facilitating and supporting GP led local initiatives
∙ CSAPHN
∙ CSAPHN facilitating and supporting GP led local initiatives.
∙ CSAPHN
∙ CSAPHN facilitating and supporting GP led local initiatives.
Priority Health Systems integration and coordination (GEN – 6)
opportunities, priorities and options - continued
Possible Options
9. Stakeholder engagement program – strengthening relationships with pharmacy sector.
10. Review current models of care and patient journey for people with cancer in the country including cost to the system and person.
11. Work with communities, ACCHOs, general practice, the six regional LHNs, metropolitan LHNs and the Rural
Doctors Workforce Agency to identify needs and enable or facilitate for provision of specialist services.
12. Enable delivery of secure telehealth services for private and public providers and increased promotion and support of telehealth initiatives through direct practice support activities. 13. Continue development of local and regional heath pathways (HealthPathways SA) from general practice to medical specialists, allied health and other service providers.
Expected Outcome
∙ Medication management review activities in place. ∙ Inclusion of inter-sectoral partners such general practice and community health services. ∙ Resources provided consistently across the region with evidence of uptake and use of same identified.
∙ Cancer Council engaged and working in partnership to improve the cancer patient journey.
∙ Effective linking of specialist and niche providers to the issue of out of hospital opportunities for care.
∙ General practice, allied health
ACCHO’s and AMS’s supported to develop and use telehealth.
∙ Improved access to services identified to meet patient need.
Potential Lead
∙ CSAPHN initiative to be managed as a partnership engagement with peak bodies who may be commissioned as required.
∙ DATIS and CSAPHN
∙ Cancer Council
∙ CSAPHN initiative in partnership with APHN,
RDWA, AHCSA and the six regional LHNs
∙ CSAPHN facilitating and supporting GP led local initiatives
∙ SA Health, APHN, CSAPHN and general practices and other key stakeholders.
Priority Health Systems integration and coordination (GEN – 6)
opportunities, priorities and options - continued
Possible Options
14. Partner with LHNs to improve discharge planning and communication with general practice for post-acute care.
15. Develop regional service directories.
Expected Outcome
∙ Improved timeliness of GP receipt of discharge plan ∙ Discharge planning undertaken appropriately with patient and carer, and documentation provided.
∙ Local service directories created and promulgated electronically.
Potential Lead
∙ CSAPHN, LHNs and general practices.
∙ CSAPHN and other key stakeholder.
