Annual Report 2022 - 2023 Darling Downs and West Moreton PHN
© Darling Downs and West Moreton PHN 2023 Aboriginal people and Torres Strait Islanders are advised that this publication may contain words, names, images and descriptions of people who have passed away.
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 1
ACKNOWLEDGEMENT OF COUNTRY: We acknowledge Aboriginal and Torres Strait Islander peoples as the Custodians of the land. We’d like to pay our respect to Elders past and present as well as emerging leaders, and commit to a future with reconciliation and renewal at its heart. We recognise that the concepts of land, family and spirituality are directly linked to Aboriginal and Torres Strait Islander peoples’ physical, mental, social, spiritual and cultural wellbeing. We would also like to recognise that Aboriginal and Torres Strait Islander peoples and communities continue to experience poorer health outcomes than other Australians, and that these inequalities must be understood within the historical context. Referencing the AIATSIS Map of Indigenous Australia, we would like to particularly acknowledge the following Countries which our region spans: Bigambul
Jagera
Ugarapul
Barunggam
Jarowair
Wakka Wakka
Giabal
Kamilaroi
Yuggera
Iman (Yiman)
Keinjan
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 2
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 3
CONTENTS 1. Healthy organisation..............................................................10
2. Healthy communities.............................................................20
3. Healthy primary care..............................................................42
4. Healthy partnerships..............................................................53 The PHN’s full financial statements are available on the Australian Charities and Not-for-Profit Commission website: www.acnc.gov.au
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 4
THE STORY BEHIND OUR ARTWORK Darling Downs and West Moreton PHN commissioned Riki Salam from 'We are 27 Creative' to develop a bespoke piece of artwork to depict the PHN's commitment to reconciliation.
CONNECTED COUNTRY, HEALING PLACE By Riki Salam Kangaroo bounds on red sands, this land is ancient and connected, wind blows all traces as life disappears. Rains renew Country, bird call pierces throughout, as landscape is coloured in diversity and grandeur. Carving its way through the land formations are created – Creation Spirit inspires song, dance, ceremony.
Water flows, knowledge is exchanged. This place of healing connects people to Country, Culture and Community. Our knowledge is in this land and we are all connected to this place, healing begins. Health and hope of the people is restored through listening, learning, sharing, caring and understanding one another.
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 5
WHO WE ARE Darling Downs and West Moreton PHN is one of 31 primary health networks around Australia. Our role in the health system is to both support primary health the health care people seek first in their community, such as GPs, pharmacies and allied health professionals – as well as work with our partners to ensure the right care is there for those who need it most.
With that comes challenges, with high birth rates, mental health concerns and elevated chronic disease across some of our most vulnerable community members. While our focus is primary care, we collaborate across the whole system to enable our communities to have access to excellent health care, closer to home.
Our region is large, around 99,000 km2 and we cover urban, regional, rural and remote areas. Our urban and regional areas are seeing some of the highest population growth in Australia.
Where needed, we commission additional services in our region, to enable equitable health and wellbeing across our lifespan.
OUR VISION
OUR PURPOSE
Healthy communities experiencing excellent healthcare, closer to home.
To work with our partners to strengthen primary healthcare for those who need it most.
OUR VALUES
Transparency
Respect
Accountability
Collaboration
OUR PHN PRIORITIES The work delivered by our PHN is framed by the seven national priorities handed to PHNs by the Department of Health and Aged Care, including Aboriginal and Torres Strait Islander health, aged care, alcohol and other drugs, digital health, health workforce, mental health and population health.
Integrity
Innovation
ABORIGINAL & TORRES STRAIT ISLANDER HEALTH
Key priority areas
POPULATION HEALTH
HEALTH WORKFORCE DIGITAL HEALTH
AGED CARE
Good governance framework
MENTAL HEALTH ALCOHOL & OTHER DRUGS
OUR STRATEGIC PRIORITIES We have broken down our strategic focus and how we plan for the work we do into four key components:
Healthy communities: Enabling equitable health and wellbeing across our lifespan.
Healthy primary care: Developing a thriving primary care system, that is strong and resilient, innovative and digitally enabled, with a supported and sustainable workforce.
Healthy partnerships: Collaborating effectively, with a one system mindset.
Healthy organisation: Empowering staff within a capable and impactful organisation.
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 6
OUR REGION Our PHN covers the Darling Downs and West Moreton region, which spans 12 local government areas (LGA).
Banana Shire Taroom
The major communities in our region are Ipswich and Toowoomba, plus the surrounding communities located in the Lockyer Valley, Scenic Rim, Somerset, South Burnett, Cherbourg, Southern Downs, Queensland Goondiwindi and Western Downs LGAs. Our region also includes communities located in the Banana Shire and Brisbane LGA.
Kingaroy Miles Chinchilla
Somerset Region
Western Downs Region Crows Nest
Dalby
Esk
The PHN region works across the language groups of: •
Jagera
•
Kamilaroi
•
Yuggera
•
Keinjan
•
Ugarapul
•
Barunggam
•
Giabal
•
Iman (Yiman)
•
Jarowair
•
Bigambul
•
Wakka Wakka
Cherbourg Aboriginal Shire
South Burnett Region
Tara
Oakey
Brisbane
Gatton Toowoomba
Lockyer Valley Region
Toowoomba Region
Ipswich Region Scenic Rim Region
Millmerran
Warwick
Goondiwindi Region
Boonah
Southern Downs Region
Goondiwindi
Stanthorpe
OUR REGIONAL SNAPSHOT Who we are:
How’s our health?
5.6%
37%
identify as Aboriginal and / Torres Strait Islander
have at least one chronic condition
37%
39.6
of adults are obese
median age (38.4 QLD)
13%
9,000
have a mental health or behavioural concerns
babies are born here annually, fertility rate 2.2 (QLD 1.8)
4.7
100,600 (16%) population born overseas, including more than 4,000 refugees
What we do
infant mortality per 1000 births (QLD 3.9 per 1000)
3% have COPD
How’s our day-to-day life? 73%
20%
don’t meet exercise guidelines
no home internet access
18%
27%
of current adults smoke
of households received rent assistance from Government
For more information, please see our health needs assessment at www.ddwmhna.com.au
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 7
CHIEF EXECUTIVE OFFICER’S MESSAGE It’s been another significant year for Darling Downs and West Moreton PHN. In the 2022-2023 financial year we continued to strengthen our position as the whole of health system champion for our region. We continued to support primary health care professionals, like GPs, general practice staff and allied health professionals, to improve the care they provide to their patients, and the development of a local sustainable health care workforce. There are many ways we engage with primary health professionals – our primary care support team provides resources and comprehensive support; our communications team distributes regular information about key health news and current affairs; and our events team coordinates meaningful educational activities relevant to their needs, in locations across the entire region. This year, our practice support team engaged with every general practice in our region, and we facilitated key events for the local primary health workforce, such as our Meet and Greets, Red Ant Roundup, Project ECHO sessions, and many more. We delivered over 140,000 emails to keep local health professionals up-to-date. We continued our TALK ABOUT campaign, which has been asking community members and health professionals about their experiences with health care since January 2020. This year’s TALK ABOUT was our greatest yet for engagement, as we engaged with 925 people across our four topics of Aboriginal and Torres Strait Islander Healthcare, Allied Healthcare, Digital Health Awareness, and Alcohol and Other Drugs. In 2022-2023, digital health remained at the forefront of our priorities. The PHN offered the ‘Connected Health Care Grants’ to Residential Aged Care Homes (RACHs) in the region to purchase the required equipment and/or enhance current information technology infrastructure for the purpose of increasing the number of video telehealth consultations offered to residents. The PHN engaged with over 92% of facilities, with 59 of 64 participating in the consultation. From this, 57 facilities applied for and were all awarded a Connected Health Care grant from the Darling Downs and West Moreton PHN. Access to health workforce in remote and rural communities continues to remain one of the greatest barriers in addressing health need in Queensland,
particularly in the primary health care setting. At the PHN we aim to be agile and responsive; we are innovative and willing to push the boundaries in the pursuit of better solutions. Through leveraging digital technology, we can expand the available workforce that rural practices may recruit from and allow rural practices to continue to service patients within the local GP practice. Thank you to the local primary care workforce who continue to provide excellent health care for our community. I would also like to thank our Board of Directors for their strategic direction and vision throughout the year, and the Clinical Council and Community Advisory Committees for their support and insight. Finally, thank you to the staff of the PHN for your innovation, passion, and commitment to making a difference. Sincerely,
Lucille Chalmers CEO, Darling Downs and West Moreton PHN
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 8
BOARD CHAIR’S MESSAGE It is with great pleasure that I present to you the 2022-2023 Annual Report for Darling Downs and West Moreton PHN. This has been another significant year of growth as we have continued to support primary health care professionals to improve the health outcomes of our community. I am pleased to report that we commissioned a total of $40 million in primary health care services this financial year. In July 2022, the Minister for Health and Aged Care established the Strengthening Medicare Taskforce, building on Australia’s Primary Health Care 10 Year Plan 2022-32, to provide recommendations on the highest priority improvements to primary care. This included the introduction of MyMedicare, which will support wrap-around care for patients registered with their local GP through new blended payment models. The welcome investment in the 2023-24 budget to lay the foundations for a stronger Medicare reflects our priority of ensuring that people in our region get greater access to affordable, quality primary health care when they need it. Mental health, suicide prevention, and alcohol and other drugs remained key priority areas for the PHN in 2022-2023. In May we announced that NEAMI National and Open Minds were selected as the service providers to deliver Head to Health in the region. The PHN will work in partnership with both service providers, along with Darling Downs Health, West Moreton Health, the co-design stakeholders, and the local community as the services are operationalised. The establishment of Ipswich and Kingaroy Head to Health sites is now underway, with initial operations anticipated for late 2023. Once established, the Head to Health centres will provide welcoming and enhanced access to mental health support through assessment and warm referrals and the national phone line will support residents in the whole Darling Downs and West Moreton region to navigate the mental health system. This year we launched our Strategic Plan 20232027 – the foundation of our work as we enter this new chapter of growth. Our strategic priorities are healthy communities, healthy primary care, healthy partnerships, and a healthy organisation. The plan outlines our ‘one perfect day,’ whereby all people living in our region will live healthier lives, backed by a connected, equitable and thriving health system.
In October 2022, we welcomed three incredible leaders with a wealth of experience to our Board: Deanne Minniecon, Elizabeth Adams and Professor Lauren Ball - with Ms Minniecon and Ms Adams also bringing invaluable knowledge and perspectives as First Nations women. We also farewelled Annette Scott who had served terms with the Board of seven years, and we would like to thank her for her significant contribution. Lastly, I would like to pay tribute to the rest of the Board. It has once again been a pleasure working with you all this year. Also, to the hard-working leadership team and staff of Darling Downs and West Moreton PHN, thank you for your tireless efforts and energy in bringing our strategic plan to life. I hope you enjoy hearing about our achievements in the 2022-2023 Annual Report and I look forward to our continued work in the year ahead. Sincerely,
Dr Tony Bayliss Board Chair, Darling Downs and West Moreton PHN
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 9
Healthy organisation
Healthy organisation
Empowering staff within a capable and impactful organisation. Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 10
Healthy organisation
YEAR AT GLANCE
$40.36M
100%
7,300+
1,608
95,713
30,490
350,127
142,140
INVESTED IN HEALTH PROGRAMS THIS YEAR
CONTACTS MADE BY THE PHN TO LOCAL PRACTICES
WEBSITE PAGEVIEWS
VIEWS OF SOCIAL MEDIA POSTS
OF GENERAL PRACTICES SUPPORTED
IMMUNISATIONS ON VAXBUX
WEBSITE VISITORS
EMAILS SENT
115,000+
1,687
1,146
925
HEALTHPATHWAYS WEBSITE PAGEVIEWS
HEALTH PROFESSIONALS ATTENDING EDUCATIONAL EVENTS
LOCALISED HEALTHPATHWAYS DEVELOPED
PEOPLE ENGAGED WITH THROUGH TALK ABOUT
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 11
Healthy organisation
OUR BOARD We are led by a highly qualified Board with a wealth of knowledge and demonstrated hands-on experience working within our region.
CHAIR Dr Tony Bayliss - General Practitioner Dr Tony Bayliss has been practising as a GP in the Ipswich area since 2012. He has served on the Darling Downs and West Moreton PHN Board since November 2017 and as Chair since 2019. He brings real-world skills and experience in clinical matters, corporate and clinical governance, finance and strategy. He has been a practice owner in the region since 2015 and retains a passion for improving the health of the Darling Downs and West Moreton communities. He is an active member of the RACGP Queensland Faculty Council and the West Moreton Local Medical Association.
BOARD MEMBERS Dr Vladislav Matic - General Practitioner Dr Vladislav (Vlad) Matic is a GP with more than twenty-five years of remote, rural, regional and urban General Practice experience. Vlad is passionate about Aboriginal and Torres Strait Islander health, chronic and complex disease management, data, and clinical governance. In addition to contributing to GP and primary care Boards over the past twenty years, Vlad has also been very involved in the teaching of medical students and GP Registrars aiming for either an FRACGP and / or FACRRM.
Dr Andy Mellis - General Practitioner Dr Andy Mellis has worked in General Practice since 2003 and has been based in Toowoomba since 2005. Andy currently works at both James Neil Medical and Rangeside Medical, in the People First Health Group. Andy trained at Nottingham University and completed his specialist general practice training in the UK, before emigrating to Toowoomba in 2005. Andy is an accredited GP trainer and is a senior lecturer with the UQ School of Medicine. Andy is a founding member of the Darling Downs and West Moreton PHN Board and is committed to keeping quality general practice accessible to all.
Megan O’Shannessy - Chief Executive Officer of Rural Medical Education Australia Megan O’Shannessy is the Chief Executive Officer of Rural Medical Education Australia, a local NFP rural health education company that delivers the Griffith University Rural Medical program on the Darling Downs and Maranoa. She is a Registered Nurse and Midwife with extensive clinical and leadership experience in rural health across the Darling Downs region. Megan is a member of the Medical Board of Queensland and the Platinum Health Group. She is an Adj Associate Professor at the Griffith University School of Medicine, has a Master of Public Health, a Bachelor of Nursing and is a GAICD.
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 12
Healthy organisation
Dr Graham McAllister - Medical Superintendent and General Practitioner Dr Graham McAllister has worked extensively as a Medical Superintendent and GP throughout South Burnett, has lived in both the West Moreton and Darling Downs areas and is originally from Ipswich. Graham has served on various Medical Boards and is a Life Member of the Royal Australian College of General Practitioners and Foundation Fellow of the Australian College of Rural and Remote Medicine. He also has a keen interest in lecturing and medical students’ education. Graham has served on the Darling Downs and West Moreton PHN Board since November 2017 and is passionate about rural medicine and education.
David Cosgrave - Lawyer David Cosgrave is a Toowoomba-based lawyer with Australian and international legal, business and management experience. David has served in a variety of executive level and Board roles across investment banking, telemedicine, health care, education, information technology and security. He has previously worked at the Northern Sydney Area Health Service (NSAHS), Crosby Asset Management, CSIRO, the University of Southern Queensland (USQ) and his own businesses. David joined the Darling Downs and West Moreton PHN Board in November 2018 and brings to the role his experience in corporate governance and strategic thinking.
Professor Lauren Ball - Professor of Community Health and Wellbeing at the University of Queensland Professor Lauren Ball is a Professor of Community Health and Wellbeing at the University of Queensland. Lauren brings over 15 years’ experience as a clinician and researcher in primary care as a qualified dietitian, exercise physiologist and primary health care researcher.
Deanne Minniecon - National Manager of Aboriginal and Torres Strait Islander Engagement at Diabetes Australia Deanne Minniecon is an Aboriginal (Goreng Goreng) and Torres Strait Islander (Erub) woman with over 25 years’ experience working in Aboriginal and Torres Strait Islander health and education. Deanne is currently the National Manager of Aboriginal and Torres Strait Islander Engagement at Diabetes Australia.
Elizabeth Adams - Chief Executive Officer of Goolburri Aboriginal Health Elizabeth Adams is currently the CEO of Goolburri Aboriginal Health. She is a proud Aboriginal woman of the Mardigan people from Southwest Queensland with over 30 years’ experience in primary health care.
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 13
Healthy organisation
OUR PEOPLE Our organisation is led by a very experienced Executive Leadership Team of four people, including the new role of Executive Director – Strategic Commissioning Framework which was introduced this year in support of our Commissioning Framework.
Lucille Chalmers - Chief Executive Officer Lucille is an experienced health and human services executive with a special focus on community health and primary health care. Lucille was previously Deputy CEO at Brisbane South PHN. Lucille has a deep commitment to improving community health and wellbeing with extensive experience in the design, delivery and commissioning of health and human services in Australia and the United Kingdom. She has a particular passion for community driven and place-based ways of working to address inequities and improve health outcomes. She is a graduate of the Australian Institute of Company Directors and holds qualifications in Business (Philanthropy and Non-Profit Studies), Masters of Public Health and Bachelor of Applied Science (Speech Pathology).
Kate McLoughlin - Executive Director - Strategy and Operations Kate serves as Chief Financial Officer and Company Secretary for Darling Downs and West Moreton PHN, where she manages the company’s finances and corporate responsibilities, and promotes a happy and healthy work culture. Prior to joining Darling Downs and West Moreton PHN, Kate served as Senior Finance Manager and Revenue Manager for Darling Downs Hospital and Health Service and Senior Business Analyst for Saxon Energy Australia. Kate holds a Bachelor’s Degree in Education and a Masters of Professional Accounting from the University of Southern Queensland, and is a Certified Practising Accountant.
Stewart Gordon - Executive Director - Primary Care and Integration Stewart has returned to work in the health sector after practising as an employment lawyer in the private sector. He began his career in healthcare, including serving as District Manager, with the Roma Health Service District in 2004. Stewart then assumed an executive position with the Darling Downs West Moreton Health Service District, where he gained significant leadership experience as Executive Director Rural Health and Aged Care. Stewart holds a Graduate Diploma in Legal Practice, Bachelor of Laws and Bachelor of Business (Marketing and Human Resource Management), University of Southern Queensland.
Jen Newbould - Executive Director - Strategic Commissioning Jen joined Darling Downs and West Moreton PHN in 2023 with over 20 years of direct experience in the commissioning context, with a focus on transformational systems change. Jen is a partnership broker and quality systems lead auditor with tertiary qualifications in management and leadership, business administration and accounting. Jen has worked with diverse communities and system partners to tackle disadvantage and to improve outcomes in mental health, suicide prevention, alcohol and other drugs, homelessness, child protection, justice and adult education, through senior leadership positions held in the UK and Australia spanning health, community services and public sector contexts.
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 14
Healthy organisation
STAFFING
61 72%
TOTAL STAFF NUMBERS
LIVE IN OUR REGION
17 44
FEMALE MALE
11 50
FULL TIME PART TIME
Some of the reasons staff find us a truly great place are:
STAFF ENGAGEMENT Since 2013, we have undertaken an annual staff engagement survey through third-party provider Best Practice Australia. The survey measures organisational culture across our PHN as well as many others, to provide us with insights into what is working well and what areas may need improvement.
Committed team, great culture, and a shared vision for what we want to achieve.
This year we had our highest scores to date, with notable results including:
95%
response rate
People are friendly, and supportive, and there is a strong, clear vision at the strategic level.
92%
are proud of our successes and achievements
98%
A positive work culture that everyone contributes to in a genuine way.
are optimistic about the organisation’s future
+67
NPS score (PHN avg +22.8)
A great culture in the workplace and a supportive management team.
94% (+5%) viewed as a “truly great place to work”
91%
finds the PHN a supportive organisation that puts values into practice
88%
It’s the best workplace I’ve ever worked at.
Good working environment with a job that challenges me.
engagement rate (PHN avg 68%)
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 15
Healthy organisation
ORGANISATION STRUCTURE CEO
Primary Care and Integration
Strategic Commissioning
Strategy and Operations
Primary Care
Mental Health
Digital Transformation, Performance and Evaluation
Business Development
Aboriginal and Torres Strait Islander Health
Priority Populations
Stakeholder Engagement and Communications
Finance, HR and Administration
HEALTH AND SAFETY We are committed to upholding a workplace that is healthy and safe. Our Health, Safety, Environment and Community (HSEC) team is proactive at ensuring we maintain staff wellbeing as well as safety, though regular wellness initiatives.
Our Springfield and Toowoomba offices also joined forces to celebrate ‘R U OK?’ Day through a virtual guided mediation with the inspirational Amy from Antara Studios. This was followed by a shared morning tea to relax and reflect on the experience.
This year we took the opportunity of ‘STEPtember’ to raise funds as well as our daily steps. In total, our staff walked 5.74 million steps, raising $889 to support people living with cerebral palsy in the process.
During May, our ‘Healthiest Morning Tea’ was a chance for our busy PHN team to connect over a cuppa, while at the same raising funds in support of the Cancer Council.
‘R U Ok?’ Day morning tea held at the Springfield office.
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 16
Healthy organisation
OUR MEMBERS Our PHN was originally formed in 2015 under a partnership between Darling Downs Health and GP Connections.
To support primary health service integration, foundational changes to the organisational structure have been undertaken with the following organisations also approved for membership:
OUR QUINTUPLE AIM FOR HEALTH CARE IMPROVEMENT The PHN uses the Quintuple Aim as an established framework for measuring improvement in the health care system. The Quintuple Aim provides a strategic perspective to the value and contribution of the PHN to the overall health of the community. It measures our local health system against quality and access, experience, satisfaction, cost and equity. This complements the PHN Program Performance and Quality Framework that articulates Australian Government expectations about the role and performance of PHNs.
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 17
Healthy organisation
RECONCILIATION Our vision for reconciliation is for Aboriginal and Torres Strait Islander peoples to have equal access to high quality primary health care and improved health and wellbeing. The development and implementation of a Reconciliation Action Plan (RAP) ensures the voices of Aboriginal and Torres Strait Islander peoples are heard and considered in all of our decisions and actions.
Some of the initiatives we have undertaken this year on our journey towards reconciliation include: •
Hosting a screening of ‘The Final Quarter’, a documentary re-examining the divisive incidents which marked the final years of AFL footballer Adam Goodes’ career.
•
‘National Reconciliation Week’ events, where staff shared what this year’s theme “Be a Voice for Generations” means for them.
By improving cultural understanding throughout our PHN, we can influence sustainable change that will incorporate the knowledge, traditions, customs and values of Aboriginal and Torres Strait Islander peoples and their cultures. With improved understanding, we will be able to provide efficient and effective support to our key health service delivery partners to improve the health of Aboriginal and Torres Strait Islander peoples in our communities.
LEARN MORE
facebook.com/DDWMPHN •
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 18
Our staff actively participate in ‘NAIDOC Week’ events across our region.
Healthy organisation
STAFF SPOTLIGHT Todd Williams Director – Aboriginal and Torres Strait Islander Health What is your role with the PHN? My role is Director – Aboriginal and Torres Strait Islander Health. For you, what is the best thing about working for the PHN? One of the best things about working for the PHN is having the ability to improve health equity and access in our region for our Aboriginal and Torres Strait Islander communities. What are you most proud of achieving in the 2022/23 FY? This year, I am extremely proud of how our PHN has been able to ensure Aboriginal and Torres Strait Islander people have been included in our planning of services in all areas of the PHN.
This year Todd also presented at Check Up’s Queensland Primary Health Care Network event about our commitment to reconciliation and Innovate Reconciliation Action Plan (RAP), along with our Director – Stakeholder Engagement and Communications, Louise Litchfield.
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 19
Healthy Communities
Healthy communities
Enabling equitable health and wellbeing across our lifespan. Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 20
Healthy Communities
BUNYA FAMILY Fundamentally, what we do is person-centred. Our person-centred approach ensures people who access health system supports and services, including carers and close supporters, are the experts of their personal health situation and need to be at the centre of our planning and commissioning decision-making. Our person-centred approach delivers care and support in partnership with the community to achieve the best outcomes for the community. This approach attempts to address the traditional power dynamic of system versus beneficiary to one where commissioners, providers and communities are equal
system partners and we will look to patient experience measures to test its effectiveness. The ‘Bunya Family’ comprises a number of avatars of community members who represent ‘real life’ scenarios within our region. Each family member is a potential consumer of services in our healthcare system and we use them to map our care journeys. The use of the Bunya Family is based on the Welsh model of the ‘Jones Family’. The NHS in Wales used the Jones Family to steer conversations toward improving patient care.
Introducing our Bunya Family:
Jamie Bunya
Kiara
Abdul-Alim
Uncle Mick
Patricia Bunya
Mani
Marnie Stephenson
Ash
Sam
Jan Bunya
Charlie (Cha Cha)
Jim Bunya
Kaz
Lauren Bunya-Smith
Jamie Bunya
Paul Bunya and family
LEARN MORE
ddwmphn.com.au/bunya-family
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 21
Healthy Communities
ABORIGINAL AND TORRES STRAIT ISLANDER HEALTH
There are more than
36.87%
33,000
rate of population receiving specific health assessments
Aboriginal and Torres Strait Islander people
Our PHN has funded services supporting 4,934 people, including 876 new patients this financial year, and 36.87% of the eligible population is receiving MBS item 715 (health assessment).
WHAT WE ARE DOING Our aims are for Aboriginal and Torres Strait Islander peoples in the Darling Downs and West Moreton PHN region to: •
have access to care within the local community that meets their health and wellbeing needs, and
•
experience improved physical, social and emotional wellbeing outcomes and life expectancy equal to or better than the nonIndigenous population.
This year, we appointed a Director - Aboriginal and Torres Strait Islander Health and a Community Engagement Coordinator, both identified roles. The Director role provides advice and guidance across our PHN both internally and externally via our Commissioned Programs. This role also supports our providers to be culturally appropriate in service delivery. The Community Engagement Coordinator role engages with the community and consumers to ensure commissioned service delivery is meeting their needs. We also refreshed our Aboriginal and Torres Strait Islander Health Strategy this year.
HOW WE ARE DOING IT Services we fund include: •
•
Integrated Team Care: offers care coordination support for individuals with a chronic condition, and general support to access health services through outreach workers. Support can include affordable medicines, transport services to and from medical appointments, and coordinated multidisciplinary care for those living with chronic disease.
•
Sunrise Way alcohol and other drugs treatment services: residential services that provide live-in, culturally appropriate treatment and support for Aboriginal and Torres Strait Islander peoples who experience alcohol and other drug dependence (refer also our section on Alcohol and Other Drugs).
•
Goondir Cultural Development Program: an opportunity to reconnect with culture providing a pathway towards reconnection to country. Participants are taken through a range of cultural activities and experiences including boomerang and didgeridoo making, cultural dance, story-telling and visits to culturally significant sites with the aim of improving their social and emotional wellbeing.
Culturally appropriate mental health services: free, culturally appropriate social and emotional wellbeing services for Aboriginal and Torres Strait Islander peoples with, or at risk of, mental health conditions (refer also our section on Mental Health).
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 22
Healthy Communities
•
•
Goolburri Early Years and Infancy Program: culturally appropriate antenatal and postnatal care in Toowoomba that offers inclusion of fathers in the early childhood phase of health care, increased access and attendance to GP, midwife and antenatal appointments, increased access to immunisation appointments, opportunistic health care for women and their children (refer also our section on Child/Youth health).
•
Youth Street Crews: engage with young people who may be experiencing a range of issues in the Toowoomba CBD area every Thursday night (refer also section on Child/ Youth health).
During July and August, we asked the Aboriginal and Torres Strait Islander community to TALK ABOUT their experience with health care in our community. This is what we heard:
Reproductive and Sexual Health Clinic: Nurse-led reproductive and sexual health clinical services to young people (refer also section on Child/Youth health).
What you thought worked well
What you thought could be done better
You continued to mention you preferred services that:
You would like to see more:
• were culturally safe • were friendly, efficient, and nonjudgmental • helped you seek and receive the best care • listen and help you understand holistic healthcare. You continued to acknowledge services for their: • professionalism and friendliness • understanding of cultural care needs • willingness to help Aboriginal and Torres Strait Islander people access available funding to offer the support needed.
• cultural and LGBTIQ+ awareness programs • Aboriginal and Torres Strait Islander health professionals in all health services • engagement with communities. You also suggested: • improving access to high-quality care in a timely, safe and effective way is essential • improving transportation services for rural and remote communities via publicly funded transport services and ridesharing services • ongoing support for those at risk of poor health outcomes through group health promotion, follow-up, casemanagement, home visiting and referral.
TALK ABOUT is a regular way we reach out to our community to check in with them about their experience with health care. Find out more page 58. Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 23
Healthy Communities
HOW THIS WORK IS MAKING A DIFFERENCE Supporting tomorrow’s Aboriginal health workforce This year we awarded grants for financial support to eight students studying a Certificate IV in Aboriginal and/or Torres Strait Islander Primary Health Care at TAFE Toowoomba. Michael Woods and Josiah Little have made major progress in their studies since receiving Aboriginal and Torres Strait Islander Study Grants from our PHN. Following the completion of his Certificate IV, Josiah plans to build a career as an Aboriginal Health Worker with a focus on advocacy and mental health support.
“I always had an interest in helping people, I was raised to look after people, young and Elders alike. Health is a good place for me to work so I can help my Mob,” said Josiah. Meanwhile, Michael is looking forward to completing his Certificate IV following a two-week practical placement at Kingaroy Hospital.
“My focus is on preventative health and supporting people to transition out of hospital and back into the community,” said Michael. Both men are passionate about the availability of culturally safe care.
“Most of our Mob feel more comfortable with an Indigenous health staff member, we are more likely to open up, there’s that shared understanding,” said Josiah. Josiah and Michael both agree this is their motivation for building careers in the health sector.
“The grant has been great, but it’s not our motivation because we are already motivated. It has fuelled the fire to keep going with our studies,” said Michael. Josiah and Michael used the funds to cover travel and transport costs, study-related subscriptions, and stationery. Our PHN will continue to support all the study grant recipients as they complete their studies and build careers in the health sector.
Josiah Little and Michael Woods stand proudly at the Toowoomba TAFE campus.
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 24
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OLDER PERSONS’ HEALTH
201K
200K
17%
150K
are 65 years and over
100K
176K 152K 120K
50K
Projected population 65 years and over
West Moreton is the fastest-growing region in Queensland (in relative terms) and our population is ageing rapidly. 58.7% of people over 75 years of age have a GP Health Assessment. By 2026, our general population is forecast to grow by 30%
0K
2026
2031
2036
2041
(to 419,000 people), while the portion of people aged 65 and older is expected to increase by 50% (to more than 60,000 people). This cohort (65 years and older), currently sitting at around 101,000 people, is projected to nearly double by 2041.
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WHAT WE ARE DOING Our Older Persons’ Health and Wellbeing Strategy – ‘Feel Well, Live Well’ – was launched in October 2022. It was developed to guide the way we plan and deliver community, primary and secondary health services to support older people to stay healthy, connected and at home. Additionally, the strategy recognises the important role families and carers play in helping to keep our older population healthy, happy, and fulfilled. ‘Feel Well, Live Well’ takes an innovative approach to system improvement, such as increasing hospital-inthe-home services to enable older people to access medical, nursing, allied health, and rehabilitation services in their place of residence.
Application of human rights
Improve accountability, monitoring and evaluation to inform health service delivery
We have a clear action plan for the next four years to implement system-wide improvements, such as the development of a single screening and assessment toolkit to ensure consistency across community, primary and secondary health services; and codesigning models of care that respond to identified service gaps.
Age friendly and culturally responsive environments
To create a West Moreton Older Persons Community that is living well in their preferred place of residence, and where the needs of the diverse and growing population are met both now and in the future.
Align our health system to older persons
Improve health outcomes for vulnerable cohorts and communities
The plan outlines actions developed following extensive consultation with a range of stakeholders including consumers, their family and carers.
LEARN MORE
ddwmphn.com.au/OlderPersonsHealth
HOW WE ARE DOING IT The programs that are playing a role in implementing our ‘Feel Well, Live Well’ action plan include: •
New Access Program: free service developed by Beyond Blue providing support in the form of a specially trained coach to residents at Residential Aged Care Homes (RACHs) with, or at risk of, a mild to moderate mental health condition. It includes a 60 minute initial assessment followed by five 30 minute sessions over six weeks.
•
Care finder: supports vulnerable older people who would not be able to arrange services without intensive support and do not have a family member or friends who can help. The PHN has funded three service providers to deliver the care finder program. Since the program began in January 2023 the program has assisted 350 people to access aged care services. The program continues to seek out eligible community members and assist them to navigate aged care.
•
Project ECHO: offers an interactive community of practice where all participants share knowledge and experience so people in underserved communities can receive high-quality care and services. The Project ECHO Older Person series extensively covered a range of topics such as cognitive
impairment, palliative care, falls, chronic wound management and more. The monthly 60-minute online sessions include presentations from panel experts, real-life case presentations by participants with discussion and collaboration around case problem solving. This year, 427 people participated in Project ECHO. •
Supporting virtual care in RACHs with Visionflex: and all-in-one telehealth cart, which includes a digital stethoscope, IR thermometer, blood pressure cuff, pulse oximeter, ECG and conferencing equipment, with an optional high-definition camera with dermatology hood and tongue depressor. It also provides video conferencing software that maximises the use of the cart peripherals, integrates with practice software and allows all interactions between patients and their remote doctor to be recorded. This year we helped to equip seven general practices and at least five residential aged care homes with a Visionflex (refer also section on Digital Health).
•
Darling Downs GCfAHPC Program: palliative care coordination and integration to support people who have a known life-limiting condition, by improving choice and quality of care and support in the home.
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 26
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•
Enhancing After Hours Support in RACHs: our PHN is currently supporting RACHs with facility-wide after-hours plans. These plans play a pivotal role in delineating strategies for managing residents’ health care during after-hours periods and increasing awareness about available health care options to mitigate unnecessary hospital transfers.
•
Dementia specific HealthPathways: new pathways to support assessment and referral to local services and supports, and enhance existing dementia related HealthPathways.
HOW THIS WORK IS MAKING A DIFFERENCE Project ECHO - Older Persons’ Mental Health Series We have collaborated with West Moreton Health, Darling Downs Health, and the University of Queensland to provide Project ECHO in the Darling Downs and West Moreton region for almost two years. Project ECHO® (Extension for Community Healthcare Outcomes) is a collaborative knowledge-sharing model designed to create a ‘learning loop’ between health professionals via Microsoft Teams, to increase knowledge and access to health care in local communities and bring care closer to home. Each session focuses on a specific topic and allows participants to contribute client cases or questions to our specialist panel and the group, to problem solve challenges, share experiences, and workshop solutionbased ideas to improve care delivery.
Legislation - Mental Health Act 2016 and Public Health Act’. The beginning of 2023 saw the Project ECHO Older Persons’ Series deliver ‘Navigating the My Aged Care System’ with presentations provided by frontline clinicians with practical tools, advice and resources discussed to support older people in the community understand My Aged Care, and the care and assistance they require. Each session attracted attendance from between 40 to 60 health care practitioners. We utilised local expertise, which has the dual impact of imparting relevant and local knowledge, while also importantly creating local networks, so people meet and connect with those that provide support in our region.
Project ECHO Older Persons’ Mental Health Series 2022 extensively covered ‘Navigating Mental Health
Michelle Canning (PHN) with Rosemary Dickson and Amanda Woolcock (West Moreton Health)
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Care finder making a difference After living at an over 50s residence for more than 15 years, Tom’s health had declined to the point where he needed to consider the next stage in life. Tom’s daughter, also living in the same over 50s residence, had her own health concerns which meant she was unable to help Tom as much as she would have liked. After 12 falls in 12 months, the residence was no longer a safe option and therefore the facility was unable to extend Tom’s lease. By the time Tom’s family reached out to the ADA Link program, Care finder, Tom’s lease was ending within seven days, causing him severe anxiety and stress. Tom did not have an account with My Aged Care nor any support for his daily living needs.
Prior to reaching out to ADA Link, Tom said he was feeling apprehensive about his future:
“I had a lot of anxiety and didn’t know what to expect. When I heard about Charbel I thought ‘Here is another person that won’t help me,’ and I was expecting disappointment.” “After meeting Charbel I was feeling elated and relieved. I understood what Charbel was going to do to help me and I could see a light at the end of the tunnel. I feel great now because Charbel took the time to get to know me and build a relationship with me. He made me feel confident and comfortable. I really felt he was there to help me. Charbel is a breath of fresh air.”
ADA Link’s Community Connector, Charbel Trad, took time to understand Tom’s needs and wants. Tom expressed that he had been angry to have to leave the facility and not happy about having to consider moving into a residential aged care home, but had come to realise that he needed this extra support. Tom was uncertain about his future and was anxious about what was going to happen if he had to move without having somewhere to go. Tom indicated that he wanted assistance to find secure and safe accommodation, where there would be extra support.
Tom with Charbel Trad.
Charbel’s immediate concern was to ensure that Tom had somewhere to stay after his lease expired. This involved many conversations with the management of the over 50s village to ensure that Tom was kept safe until he was able to find a placement in a residential facility. ADA Link helped Tom to: •
set up an account with My Aged Care and supported him with the ACAT assessment
•
negotiate with the Manger of the residence to allow Tom to stay on until secure accommodation was found
•
source appropriate Aged Care facilities for Tom, assisting with all the paperwork
•
organised and assisted with the income and asset assessment with Services Australia
•
source assistance with packing up his unit and moving into the facility
•
ensure his needs were heard at the facility with management
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MENTAL HEALTH AND SUICIDE PREVENTION
13.2
133,994
16.8
psychological distress (18+) per 100
mental health conditions
suicide deaths per 100,000
WHAT WE ARE DOING Our PHN is committed to ensuring that all people living with a mental health condition and alcohol and other drug use in our region can access effective and appropriate treatment. The joint regional comprehensive Mental Health, Suicide Prevention, Alcohol and Other Drug Plan 2021 2026 titled 'Healthy Minds, Healthy Lives' was launched in 2021. It aims to improve access to mental health, suicide prevention and alcohol and other drug services in the Darling Downs and West Moreton region. ‘Healthy Minds, Healthy Lives’ outlines a plan based around four key areas: 1.
integration and coordination
2.
availability, awareness and access of service
3.
workforce and support
4.
services that meet the needs of individuals, specific populations and changing needs across the lifespan.
Our PHN funds primary mental health services within a person-centred stepped care approach.
Stepped care ensures people can access the most appropriate service at any given time and move through the continuum of care as their needs change. The five levels of stepped care are: • Level 1: self-management • Level 2: low intensity • Level 3: moderate intensity • Level 4: high intensity • Level 5: acute and specialist. We primarily focus on the provision of care up to level 4, with level 5 services being coordinated through the state health/hospital system. This year we also undertook a rigorous tender process to identify a suitable provider for two Head to Health centres in our region. Head to Health centres will offer a free service, available every day of the year, that provides a safe and welcoming space for people who may be in distress or crisis, or who need help finding the right mental health services for their individual needs. Our Head to Health centres will be located in Ipswich and Kingaroy, and open during the next financial year.
Healthy Minds Healthy Lives Roadshow - Goondiwindi
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HOW WE ARE DOING IT We fund a range of mental health and suicide prevention services: •
•
Head to Health phone line: for consumers, their families, carers, GPs, service providers and other health professionals, available Monday to Friday, 8:30am to 5pm (except public holidays). The Older Men’s Network (TOMNET): specialised support services and peer programs for men over 50, especially those at risk. Program offers up to 12 face to face or telephone sessions to help men manage anxiety and depression.
•
Psychosocial Support: peer support for people who are diagnosed with a severe and complex mental health condition who are currently being managed in the primary care setting via a GP and/or psychiatrist.
•
Creative Coping: a 20-week group therapy program that helps people build skills to manage overwhelming thoughts and emotions, reduce distress and make life changes.
•
Mental Health Nurse Care: mental health nurse services through a clinic setting or outreach model including clinical care coordination of services by a mental health nurse.
•
Targeted Psychological Therapies (TPT): provides psychological support to people with a mild to moderate mental health condition
•
Child and Youth Mental Health Services: non-clinical care coordination to support the young person, complementary to clinical therapeutic interventions, GPs, paediatricians and psychiatrists.
•
Suicide Prevention – Healing Workshops: service options include the Find Healing (through Culture) and Walkabout Barber workshops, and access to integrated health services.
•
Headspace: can assist young people aged 12 to 25 years with mental health, general health, drug, alcohol, education and employment issues.
•
Suicide Prevention – The Way Back Support Service: one-on-one, non-clinical care and practical support that people can relate to following a suicide attempt. Support is provided for up to three months and targets those at the highest risk through referrals following hospital presentations.
•
Per- and Poly-Fluoroalkyl Substances Program: offers free, specialised and confidential counselling services to people affected by PFAS in the Oakey area.
•
Aboriginal and Torres Strait Islander Mental Health and Suicide Prevention services: culturally appropriate mental health services, including suicide prevention services, for Aboriginal and Torres Strait Islander people (refer also Aboriginal Health section).
•
Suicide Prevention – Reach Out and Recover (ROaR) Service: culturally appropriate suicide prevention service that will support the client (and their care givers) to work with a range of practitioners including GPs, psychiatrists, addiction medicine specialists, psychologists, social workers, counsellors, nurses and Aboriginal health workers.
•
APOP Outreach program: outreach mental health service supporting children (infant to 11 yrs) and their families to improve mental health and wellbeing, reduce waiting lists for local mental health services, and support the schools who are also supporting these vulnerable families.
•
New Access: free service developed by Beyond Blue that provides support in the form of a specially trained coach and includes a 60 minute initial assessment followed by five x 30 minute sessions over six weeks. This service is specifically tailored for an older person’s needs. (refer also Older Persons’ Health section).
•
Youth Insearch: peer-led youth suicide prevention program for young people aged between 12-24 (refer also Child and Youth Health).
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HOW THIS WORK IS MAKING A DIFFERENCE APOP supporting families Recent natural disasters and the resulting distress and trauma in the West Moreton region led to the mental health system experiencing greater demand than ever before. Long waitlists meant children could not get mental health support when they needed it. So we worked with Accoras to deliver the Accoras Psychosocial Outreach Program (APOP) as a pilot service to respond to this emergent need. The program provided goal-focused, holistic, and tailored support and brief case management for children with (or at risk of developing) severe mental illness or impaired psychosocial functioning. Goals are tailored to the individual needs, lives and strengths of children and families, focusing on: •
emotional and physical health and wellbeing
•
improving school engagement
•
functioning and communication in both parents and children
•
building key life skills to help children flourish.
APOP, based within Silkstone State School, supported children, families and schools across the West Moreton region. Intervention was delivered in homes and schools, where support was most needed, and the techniques learnt needed to be applied.
Accoras’ General Manager, Suzie Lewis, reflected on the necessity of the service:
“APOP is reaching children and families who have been missing out – either because they were on long waitlists, or not able to access mental health support at all. It is a critical service equipped to respond to severe and complex mental illness in a way that centres the child, resources the family, and involves schools and other key community supporters.” The service has been very well received by local services, school, and families. One mother told Lewis: “You guys (APOP) have done amazing with my child. He is no longer having meltdowns when having hard conversations about his responsibilities and his emotions. Before getting help from you, both [my son] and I were scared of me going back as he would have no-one to help him when the school called. Now, we're not as worried. I haven't had to pick him once since the beginning of the school year. I know he can selfregulate and solve his problems. And he knows it too.”
Kelly Dowdell, Megan Ross, Haiying Dong and Georgia Scott (from Accoras)
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Co-designing the future of primary mental healthcare Head to Health is a network of programs, phone services, online resources and service centres for people needing mental health support.
Both the Kingaroy satellite and the Ipswich service centre are anticipated to begin operations in late 2023.
In August, we started the process of co-designing our future Head to Health services for the region. The Head to Health services will be a satellite service in Kingaroy, and a service centre in Ipswich. These new services will operate in addition to existing local services and the Head to Health phone line. Each workshop panel included people with lived experience, carers, local service providers, council representatives and representatives from West Moreton Health and Darling Downs Health. The co-design sessions were an opportunity for all panel members to share and discuss their experiences and perspectives. Their valuable input will inform all future stages of the project.
Co-design panel in action
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 32
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ALCOHOL AND OTHER DRUGS (ADDICTION SUPPORT)
17.7
17.2
3 IN 4
current smoker (18+) per 100
> 2 standard alcoholic drinks per day (18+) per 100
people in our region discussed their usage of alcohol and other drugs with their GP
56%
1 IN 3
of those receiving support were aged 20 – 39 years
had cannabis as their main substance of concern, followed by amphetamines, alcohol and opioids
WHAT WE ARE DOING Our PHN works with service providers to improve access to treatment and coordination of care for people who experience alcohol and other drug dependence. This year, we also reached out to our community to
TALK ABOUT their experiences with addiction support services. Overall, they rated their confidence in using health services for alcohol and other drugs with a score of 5 out of 10. They told us:
What you thought worked well
What you thought could be done better
You mentioned:
You would like to see more...
• flexible delivery options such as virtual support, home visits and suitable hours of operation
• support for early intervention and underlying issues that can lead to use and addiction
• peer support.
• integration of care such as with mental health and social services
You continue to acknowledge services for their...
• peer workers and training for service providers about how to reduce stigma
• supportive and non-judgmental environment
• deep and meaningful engagement and consumer-led service design.
• privacy and confidentiality • professional expertise in helping with your needs and finding solutions in your treatment journey.
This year, we have continued to engage, consult, and co-design our programs in collaboration with local Aboriginal and Torres Strait Islander Community Controlled services, such as Carbal Health Services, Cherbourg Regional Aboriginal and Islander Health Service, Goondir Health Services, Goolburri Health Services, and Kambu Health Service. We also
You also suggested more... • outreach programs • flexible delivery of services, such as virtual and after hours services, to suit the individual’s situation.
engage in partnerships with Queensland Aboriginal and Islander Health Council and the Queensland Indigenous Alcohol and Other Drugs Network, which ensures our initiatives are not only culturally sensitive but also tailored to address the unique needs of the local community.
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HOW WE ARE DOING IT Some of the addiction support/alcohol and other drug services we have commissioned this year include: •
•
Lives Lived Well (Non-residential): alcohol and other drug counsellors provide nonresidential rehabilitation services, including culturally appropriate care for Aboriginal and Torres Strait Islanders.
•
Sunrise Way (culturally appropriate services): culturally appropriate residential alcohol and other drug rehabilitation service based in Toowoomba (refer also Aboriginal and Torres Strait Islander Health section).
•
Teen Challenge: assistance to individuals aged 18 – 45 to locate and access treatment options appropriate to their alcohol and other drug use issue, including residential rehabilitation. The service also provides a regional outreach service providing assessment and preadmission support.
Sunrise Way (residential): residential alcohol and other drug rehabilitation based in Toowoomba.
HOW THIS WORK IS MAKING A DIFFERENCE Lives Lived Well supporting recovery Our commissioned service provider ‘Lives Lived Well’ helped a 48-year-old male client on a journey of healing through their Alcohol and Other Drugs program. With a history of alcohol misuse, mental health struggles, relationship difficulties, and selfdestructive behavior, upon joining the program, the client underwent a thorough assessment to address his specific challenges.
the Alcohol and Other Drugs program provided by ‘Lives Lived Well’ empowers individuals to reclaim their lives and embrace a brighter future.
Psychoeducation sessions were implemented to equip the client with knowledge and coping strategies for triggers, high-risk situations, lapses, and relapses. Techniques like breathing exercises and mindfulness practices were introduced to promote emotional regulation. Therapeutic modalities such as Acceptance Commitment Therapy, Cognitive Behavioral Therapy, and Dialectical Behavior Therapy were employed to support his progress. The program emphasised harm minimisation, tailoring approaches to meet the client’s individual needs. Education on trauma and the development of boundaries and communication skills played a significant role in his journey. The client’s relationship with his wife improved, fostering shared activities and responsible alcohol use. Notable reductions in depression and anxiety scores indicated enhanced well-being. Quality of life scores, encompassing psychological wellbeing and physical health, showed significant improvements. Follow-up scores demonstrated the sustainability of positive change. Substance use decreased, and the client’s confidence in controlling alcohol use increased. Grateful for the newfound coping mechanisms and personal growth, the client expressed his appreciation for the support received. This journey serves as a testament to resilience, dedication, and the power of tailored support and how
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 34
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POPULATION HEALTH CHILD AND YOUTH
8.2K
16.1%
7.3%
4.6%
births in our region
smoking during pregnancy
low birth weight babies
infant deaths per 1000
67.72%
58.1%
43.3%
71.3%
fully breastfed at 3 months
did not attend antenatal care in the first 10 weeks
children aged 4 and 5 enrolled in preschool
children developmentally on track in physical domain
WHAT WE ARE DOING Over 12,000 children in Queensland have been placed under the protection of a Child Protection Order. According to Children’s Health Queensland, nine out of ten children and young people in out-of-home care
(OOHC) have unmet health needs. We work in partnership with local stakeholders to improve access to primary health care for this vulnerable group.
HOW WE ARE DOING IT •
Project ECHO - Paediatric/Children’s Health Series: improved timely access to care, delivered as close to home as possible, out of hospital if appropriate, and through partnerships with primary care and community providers. The topics in this educational series for health care professionals included Paediatric Eating Disorders, Mind Body Symptoms: FSS Explained, Gender Medicine for Medical Prescribers, Rethinking the Crying Baby, and Paediatric Disability including NDIS access.
•
Strengthening Health Assessment Pathways (SHAP): this initiative raised awareness amongst local health professionals of the importance of health and development assessments, and early intervention plans for the vulnerable demographic of children and young people in OOHC, including 178 downloads of the newly developed child assessment.
•
Maternity Symposium: an annual event that brings together GPs, midwives and other health professionals to discuss how to better align antenatal care services in our region. It offers a collective approach to support local health professionals to provide safe, womancentred maternity care.
•
Youth Insearch Foundation: Peer-led youth suicide prevention program for young people aged between 12-24 (refer also mental health section).
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HOW THIS WORK IS MAKING A DIFFERENCE Youth Insearch Foundation In January 2023, we commenced a partnership with the Youth Insearch Foundation (Aust) to deliver their trauma informed mental health support program to young people aged 12-25 years in the Lockyer Valley. The program provides support through weekly support groups, weekend workshops and case management (where required). The program is a comprehensive model, which provides young people with a steppedcare intervention aimed at providing the right care at the right time. The first weekend workshop was held in Bundaberg with two young people from the Lockyer Valley attending. This enables young people to connect and build positive relationships with young people from other locations. A social worker has been employed and is working closely with two secondary schools located in the Lockyer Valley and one alternate training and education service. Referrals into the program have been received through these connections and the schools have reported they are seeing positive results from the investment in having the Youth Insearch Program available in their area.
Strengthening Health Assessment Pathways (SHAP) The Strengthening Health Assessment Pathways program has been invaluable in encouraging GPs in our region to recognise and manage the complex health needs of children and young people entering and leaving the child protection system. Some of our significant achievements through this program during the year include: •
The creation of Health and Development Assessment Templates, as well resources and processes between Child Safety and GPs
•
Engagement with every primary care/ medical practice throughout our region, and coordinating educational activities to support the availability of new materials and processes
•
Supporting the installation of a secure web transfer system to share confidential health assessment information electronically with Child Safety, with recommendation to roll this out across the State.
•
Inclusion of relevant out-of-home care information in both the Darling Downs and West Moreton HealthPathways websites
•
Promotion of the importance of health and
development for young people •
Facilitation of Community of Practice groups
•
Submission to ACCRM and RACGP to include Children in Out-of-Home-Care into training modules for GP trainees
Our program to build awareness of the health needs of children and young people in out-of-home-care within the primary care sector has resulted in our region having the largest number of uploads of assessment templates and tripling of the number of assessments being provided to Child Care Services, thus ensuring improved continuity of care for one of the most vulnerable cohorts in our community.
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 36
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POPULATION HEALTH PRIORITY POPULATIONS
87,343
73,132
28,787
arthritis
asthma
diabetes mellitus
28,558
21,323
21,476
heart, stroke and vascular disease
osteoporosis
COPD
WHAT WE ARE DOING Population health focus on populations with greater needs and therefore potentially greater health care inequity. This includes culturally and linguistically diverse groups who may not speak English or for whom it
may not be their prime language; refugees; and those experiencing complex and chronic illness, such as diabetes and chronic obstructive pulmonary disorder (COPD).
HOW WE ARE DOING IT •
Chronic Conditions program: recommissioned until 30 June 2024, the program focuses on making an impact in the identified regions of Somerset, Southern Downs, Western Downs and Goondiwindi. These regions were selected based on their population of ‘rising risk’ - people with one or two chronic conditions, balanced with consideration of other services in the region. Focused risk factors/conditions include obesity, physical inactivity, respiratory disease, arthritis, diabetes, cardiovascular disease and chronic pain.
•
Refugee Health Outreach program: provides support and care coordination services to newly arrived refugees by coordinating access for patients to GP and allied health services, supporting general practice to conduct Refugee Health Assessments and improve health literacy.
•
Healthy Living on a Budget: a six-week program for people diagnosed with a chronic condition that have exhausted other funding options, such as health insurance, DVA, Medicare or NDIS funding.
•
My Health for Life: a free behaviour change program designed for people at high risk of developing a chronic disease. The program works in partnership with GPs and other clinical services to provide patients with the opportunity to participate in an evidencebased lifestyle modification program in their local community.
•
Interpreting for Allied Health Professionals Program: interpreting services for allied health professionals treating patients from refugee and multicultural backgrounds across our region, with access to private allied health services by non-English speaking clients; interpreter services at nil cost to allied health professionals working in private practice to communicate with non-English speaking clients/refugee clients; and phone interpreting services.
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HOW THIS WORK IS MAKING A DIFFERENCE Improving health for a patient with chronic conditions Earlier this year, an 80 year old female client presented to one of our commissioned service providers with issues of chronic osteoarthritis pain that was impacting her ability to self-care; her mobility; and her overall mental wellbeing. She was initially resistant to surgery and was able to lessen her pain through exercise to manage her condition and avoid worsening symptoms. She eventually agreed with her doctor to discuss her situation with an Orthopaedic surgeon and then committed to a total hip replacement. Through PHN funding, the service provider was able to address the patient’s needs in the lead up to the surgery, to run through exercises for reducing risk of negative outcomes, and improve her health and fitness going into the surgery. When the patient approached the surgery, she felt well-educated in terms of postsurgical expectations.
The patient was able to commit to specialised exercises and she has been improving well, meeting key progression markers. The surgeon commented that she was in a minority of clients who actively adhered to pre and post operative exercise guidelines and attributed that success to her access to an exercise physiologist. The patient is now returning to being an active member of the community through her various committees and social groups, no longer needing allied health services at the hospital, and able to be treated within a primary care setting in her rural area. This decreased the burden of service delivery of the treating hospital and maximised client belief in suitable accessibility and treatment within her own community. The client has progressed her exercise program independently and has been discharged from allied health support.
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 38
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POPULATION HEALTH PREVENTATIVE HEALTH: SCREENING AND IMMUNISATION
52%
36%
56%
$58,820
eligible people screened for breast cancer in our region
eligible people screened for bowel cancer in our region
eligible people screened for cervical cancer in our region
cancer screening grants
1,608
6,115
94.77%
96%
FluVax bus immunisations
kms travelled by the vaxbus
under 5 fully immunised
Aboriginal and Torres Strait Islander under 5 immunised
WHAT WE ARE DOING Cancer Screening We actively work with practices to support them in raising awareness and prompting eligible patients to undertake screening. This year our work included: •
•
Grant for cancer screening: provided $58,820 in grants to primary care to increase the uptake of cancer screening among under, never-screened and overdue groups Digital toolkits through PenCS/PIP QI: provide quality improvement activities and reporting capability to help practices identify improved care opportunities for patients
Immunisation Our PHN supports primary care vaccine providers to increase immunisation coverage in the Darling Downs and West Moreton region through the National Immunisation Program Schedule and the Queensland Immunisation Program. This year we have also coordinated the transfer of more than 60,000 doses of COVID vaccines between general practices in order to minimise wastage and ensure timely vaccination administration. This was a localised solution to redistribute vaccines to where they were most needed and is estimated to have prevented the loss of more than $2M worth of vaccine product.
HOW THIS WORK IS MAKING A DIFFERENCE VaxBus bringing vaccines to the community Our VaxBus has spent the year travelling the region to break down barriers to accessing COVID-19 vaccines and boosters for children and adults, and free Influenza vaccines for everyone aged five years or older. The innovative approach offered free vaccines to community members, particularly those who may experience barriers to access such as location, transport, language, or disability. The schedules for the tour were designed with flexibility to ensure maximum coverage across our region. •
the Winter VaxBus visited over 26 locations and delivered 496 vaccinations
•
the Spring VaxBus made 26 stops delivering just under 500 vaccinations
•
the Summer VaxBus stopped at 17 locations supporting 96 people to get vaccinated.
•
the Autumn VaxBus made 15 stops providing an impressive 630 vaccinations
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 39
Healthy Communities
POPULATION HEALTH HELPING OUR COMMUNITY THROUGH DISASTERS
$218,307
24
$87,430
23
in community, wellbeing and resilience grants
community groups supported
in Primary Care Disaster Resilience Grants
general practices supported
WHAT WE ARE DOING •
Community wellbeing and resilience grants: 24 grants totalling $218,307 were given to local food-affected community groups and organisations to help support community recovery activities following the 2022 floods.
•
Primary Care Disaster Resilience Grants: 23 grants totalling $87,430 were given to local general practices that were impacted by the 2022 flood event. The grants were to directly support these practices to return to their normal COVID-19 vaccination administration capabilities.
HOW THIS WORK IS MAKING A DIFFERENCE Educultural wellbeing and healing program One of the initiatives funded through the Community Wellbeing and Resilience Grants is an educultural wellbeing and healing program by Winangali Infusion. The program was delivered during the Christmas school holidays, providing an opportunity for First Nations Goondiwindi and surrounding communities youth to connect to self, country, and community as a tool to empower themselves and develop positive wellbeing and resilience. Between 30-45 children attended. This supported meaningful revitalisation and maintenance of strong connections to Gamilaraay cultural healing practices such as song, dance, art, language, and storytelling to foster cultural identity and a sense of belonging to self, community, and country.
their family, peer networks, and school community environments also. Positive feedback from parents and community members, evidencing increased confidence and the breaking down of barriers associated with low selfesteem and shame.
The program provided supervised opportunities for prosocial connection, recreational activity, cultural education and healing, and dance workshops. Healthy lifestyle behaviours were also promoted, supporting the children to reconnect with country, learning about and experiencing the benefits of bush tukka and their medicinal purposes (physical and spiritual). This extended to on country site visits, learning about the cultural significance of local sacred areas, places, and how to use the hidden messages embedded in Gamilaraay stories to empower themselves to make better choices not only personally, but within
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 40
Healthy Communities
STAFF SPOTLIGHT Renata Danisevska Digital Health Coordinator What is your role with the PHN? My role is digital health lead. It is a diverse role that entails different aspects of digital transformation of primary care. I work with all primary care providers GPs, pharmacies, allied health providers, specialists and aged care homes. For you, what is the best thing about working for the PHN? The best thing is that I get to see people transform their practices, service delivery, implement new models of care enabled by different digital health tools. I am passionate about workforce upskilling and change management. I love the opportunity to work on different national initiatives that bring care closer to home, getting patients involved in their care, like electronic prescribing. What are you most proud of achieving in the 2022/23 FY? Developing digital transformation strategy for our PHN, and undertaking digital health consultations with our general practices and aged care homes that informed the redistribution of grants to support digital health capability and capacity uplift across the region. In early July 2023 I then had an amazing opportunity to share the insights from the aged care and prison health projects at the international conference Medinfo23 in Sydney.
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 41
Healthy primary care
Developing a thriving primary care system, that is strong and resilient, innovative and digitally enabled, with a supported and sustainable workforce. Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 42
Healthy primary care
972
181
GPs IN OUR REGION
GENERAL PRACTICES IN OUR REGION
403
161
699
189.59
PRACTICE NURSES IN OUR REGION
PHARMACIES IN OUR REGION
ALLIED HEALTH PRACTICES IN OUR REGION
ALLIED HEALTH PROFESSIONALS IN OUR REGION PER 100,000
4,284,672
810,000+
GP SERVICES
TELEHEALTH CONSULTS
SUPPORTING OUR PRIMARY CARE WORKFORCE
163
7,300+
$50,000
$2,882,500
95,713
of practices accredited
contacts with practices
in funding scholarships for Aboriginal health workers
given in Strengthening Medicare Grants
Website pageviews
142,140
33
1,146
100%
116
emails
events held
attendees at events
of practices our practice support team has supported
jobs posted on PHN website
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 43
Healthy primary care
PRIMARY CARE SUPPORT Our primary care liaison team has the important role of working collaboratively with general practices, GPs and allied health professionals to implement models of care that reflect best practice in primary healthcare through the use of data driven quality improvement initiatives. Their work includes support in the areas of: •
Accreditation: our primary care liaison team works closely with general practices to support the accreditation process.
•
Workforce recruitment: we regularly promote local primary care job vacancies in the area through our website.
•
Strengthening Medicare – General Practice Grants: this program is helping general practices and eligible Aboriginal Community Controlled Health Organisations (ACCHOs) to expand patient access and improve general practice services. The grants will support general practices and eligible ACCHOs to make investments in innovation, training, equipment, and minor capital works.
•
GP Smart Referrals: we support the use of GP Smart Referrals, which are digital referrals integrated with GP practice management software (currently Best Practice and Medical Director) to enable faster, streamlined management of referrals to Queensland Public Hospitals.
•
Aboriginal Health Workforce funding of scholarships: this supported the recruitment of much needed Aboriginal Health workers in our region.
•
EAP program for general practices: this service is offered to GPs, general practice staff and their families in response to the increased work pressures across the health sector due to the COVID-19 pandemic.
•
General Practice Liaison Officers: we engage two GPs as General Practice Liaison Officers, who attend GP practice visits with our primary care liaison team and provide education regarding the PHN's and Queensland Health programs designed to support and assist in connecting patients to the right care in the right place and the right time.
•
General practice workforce planning and prioritisation program: this project will support the transition to college-led GP training through the provision of independent, evidence-based advice to the department and colleges (ACRRM and RACGP) on registrar placement in our region. It will also provide advice on the training capacity and support needs in our region, and will provide a detailed analysis of the various training pathways and recommendations to support the attraction and retention of young rural doctors in West Moreton and Darling Downs. Over the last six months our PHN has engaged in regionwide stakeholder consultation with general practices to understand their workforce needs, the distribution and capacity of GP registrar supervisors amongst our general practices, and their overall capabilities in relation to training the future workforce.
Our primary care support team
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 44
Healthy primary care
HOW THIS WORK IS MAKING A DIFFERENCE Strengthening Medicare - implications for your practice from the 2023 budget In June, we hosted sister events to inform local health professionals about this key initiative, which will commence in late 2023. A breakfast was held at the Brisbane Lions AFL grounds in Springfield for West Moreton general practices, and a dinner was held in Toowoomba for general practices in the Darling Downs area. Our special guest speakers Dr Walid (Wally) Jammal and Dr Steven Hambleton were joined by nearly 100 GPs, nurses, practice staff, allied health, and other health professionals to discuss Strengthening Medicare from the 2023-24 budget, and implications for practices. The Minister for Health and Aged Care established the Strengthening Medicare Taskforce, building on Australia’s Primary Health Care 10 Year Plan 2022-32, to provide recommendations on the highest priority improvements to primary care. The measures include: •
supporting workforces to work at top of scope, including pharmacists and paramedics
•
expanding the nursing workforce to improve access to primary care
•
improving access to and delivery of afterhours primary care
•
introducing MyMedicare to support wraparound care for patients registered with their local GP through new blended payment models
•
providing flexible funding for multidisciplinary team-based models to improve quality of care
•
investing in digital health to improve health outcomes.
Dr Jammal and Dr Hambleton covered how the taskforce report is now driving national policy, and the particular impacts to general practice regarding changes to MBS billing, team care payments and patient registration. They also took a deep dive into the introduction of MyMedicare, a model of voluntary patient registration to support quality continuity of care and new blended funding models for practices and providers. Speaking on the investment in the 2023-24 budget to lay the foundations for a stronger Medicare, our CEO, Lucille Chalmers, said “Our priority is ensuring that people in our region get greater access to affordable, quality primary health care when they need it.”
“This event has been a great opportunity for our health workforce to gain an expert-level insight into how the focus on strengthening Medicare in the 2023-24 budget will positively impact their practices and patients.”
The ‘Strengthening Medicare’ event at Springfield in June.
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 45
Healthy primary care
COMMUNICATIONS SUPPORT AND EDUCATION Our communications team sorts through the maze of information that is relevant for local health professionals and supports the distribution of key healthcare information from government and other clinical sources. They also are responsible for sharing important information about the many services and resources our PHN offers. Throughout local disaster and emergency situations, including pandemic and flood events, they have coordinated timely alerts and information provision. Our website and emails are trustworthy sources of up-to-date information, with over 142,000 emails delivered and nearly 100,000 website pageviews this year. Our content has been viewed 350,000 times through our social media channels, which have now expanded to include Instagram.
Some educational highlights of this year include: •
Annual Maternity Shared Care symposium: where GPs were given the opportunity to hold community of practice style conversations with local and interstate paediatric specialists.
•
Red Ant Round Up: run by the PHN since 2015 and regarded as a leading rural health biennial conference. The name pays homage to the Aboriginal Wakka Wakka word ‘Kingaroori’ — meaning ‘red ant’ — from which the name of Kingaroy (the location of the event) is derived.
•
Strengthening Medicare: Australian health care luminaries, Drs Waleed Jamal and Steve Hambleton, shared their wisdom and insights about the Strengthening Medicare initiative, which is being rolled out to health care professionals during 2023/24 (refer previous page).
In support of a skilled local health care workforce, our hard-working education team partners with a range of providers, subject matter experts and professional bodies to deliver a calendar of regular, high quality continuing professional development (CPD) events to health professionals in our region.
Our communications team
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 46
Healthy primary care
HOW THIS WORK IS MAKING A DIFFERENCE Red Ant Round-Up The biennial Red Ant Round-Up conference was held in Kingaroy on Saturday, 11 March 2023. The conference theme of ‘Mental health across the lifespan’ covered a broad range of topics including health professionals’ mental health, sexual health and gender dysphoria, culturally safe health care, older persons’ wellbeing, teenage mental health, and diagnosing ADHD and other conditions in adults. This event was targeted at GPs, a wide range of medical and healthcare professionals, medical students, practice staff, medical educators and service providers. It aimed to provide a platform to deliver information to health professionals living and working in rural and regional communities to build the capacity of the rural health workforce. This year’s topic of Mental Health and Wellbeing was timely following the pandemic and natural disasters which have impacted rural communities and increased pressure on primary care. The conference allowed professionals to develop knowledge, get inspired, and grow their professional network. Health professionals from across Australia including GPs, a wide range of medical and healthcare professionals, medical students, practice staff, medical educators and service providers were invited to attend. This year’s keynote speaker, journalist and author Rick Morton spoke candidly about his experiences interacting with health professionals in rural Queensland, along with other themes of family trauma, poverty and mental health.
Participants at this year’s Red Ant Round Up
Red Ant Round Up 2023 attracted 88 participants, with 83% saying it was good value for money.
It’s run very well
Fantastic conference
It was really great and I feel more clinicians could really benefit
The speakers this year were really good quality
It was excellent
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 47
Healthy primary care
115,000+
1,687
29,500+
HealthPathways pageviews
localised pathways
healthpathway sessions
HealthPathways is a web-based portal designed to support clinicians as they guide their patients through the local public and private health systems. Designed to be used at the point of care by GPs and other health care professionals, HealthPathways provides evidence-based information on the assessment and management of a range of clinical conditions – including clear referral guidance for local hospitals, specialists and allied health. There are two HealthPathways websites for our region: one for Darling Downs and one for West Moreton.
DARLING DOWNS HEALTHPATHWAYS ddwmphn.com.au/DDhealthpathways
Each year, we continue to expand the conditions and medical topics available through HealthPathways, tailored with information about local points to refer patients to. The pathways represent the ongoing collaboration between the PHN and health care providers in the region, ensuring improved health outcomes through reduced wait times and reliable treatment guidance presented to clinicians alongside referral options in one place. In February, we reached a significant milestone, with each HealthPathways portal hitting over 800 live, localised pathways.
WEST MORETON HEALTHPATHWAYS ddwmphn.com.au/WMhealthpathways
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 48
Healthy primary care
DIGITAL HEALTH
142 practices sharing data, and in a QI program or clinical audit
137 practices registered with QH GP Smart Referrals
810,000+ telehealth consults in our region
145 practices undertaking telehealth services
providers registered with My Health Record
$242,000 in connected care grants
•
•
Digital Maturity Assessment: to better understand the spectrum of digital health maturity across general practices helped us to support a differentiated approach to digital health change and adoption based upon digital maturity. 86 practices provided responses to the Digital Maturity Assessment survey (47%). Following consultations, general practices were offered ‘Connected care grants’ providing an opportunity to modernise practices to improve their digital health capability and capacity. Funds from these Grants were spent on technology usage, cyber security, disaster recovery, information sharing (i.e. secure messaging and Discharge Summaries), eReferrals, medical record keeping and models of care. Connected Care Grants: for residential aged care homes (RACHs) located within the region to purchase the required equipment and/ or enhance current IT infrastructure in order to increase the number of video telehealth
288,368 views of different documents in My Health Record
•
QI Improvement and Clinical Audits: we promoted adoption and use of My Health Record to primary care providers (general practices, pharmacies, some allied health providers and specialists). Over 95% of general practices and 97% of pharmacies connect to My Health Record. 142 practices took part in our PHN’s Quality Improvement initiatives and clinical audits this year.
•
Visionflex and supporting virtual care in RACHs: a telehealth cart that provides Video Conferencing Software using digital peripherals such as a digital stethoscope, IR thermometer, blood pressure cuff, pulse oximeter and ECG and integrating with practice software to patients to consult with their doctor remotely. (refer also Older Persons’ Health section).
•
MyHealthRecord: we promoted the adoption and use of My Health Record to primary care providers (general practices, pharmacies, some allied health providers and specialists). Over 95% of general practices and 97% of pharmacies connect to My Health Record. We also actively promoted the new My Health app to both consumers and providers.
•
Provider Connect Australia: is a secure, online portal for providers, connecting providers. As one of the participants in the Provider Connect Australia pilot, we successfully registered providers as part of the pilot.
Key digital health initiatives this year include: An increase in the use of telehealth: during this post COVID period, there has been continued growth in the support and use of telehealth to manage and monitor the health of patients when face to face care may not be possible.
accredited practices using secure messaging
consultations offered to residents. Fifty nine out of 64 RACHs participated in the consultation process. Fifty seven of those 59 RACHs, made submissions for grants, with all those applying being successful in receiving grants (refer also Older Persons’ Health section).
This year we have supported practices to renew their NASH certificates from SHA1 to SHA2, and transition from Medicare PKI certificates to webservices through face to face interactions as well as educational events. •
137
digital maturity assessments and/ or participating in clinical audits
6,748,490 different documents shared to My Health Record
Digital health refers to using technology to improve the health care system for providers and patients alike, and improve health outcomes for Australians. Digital health includes telehealth, electronic prescriptions, secure messaging and My Health Record. We provide support to local health professionals to help them leverage the benefits of digital health to ultimately improve patient’s health outcomes.
89
645
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 49
Healthy primary care
HOW THIS WORK IS MAKING A DIFFERENCE Digital health innovation Betty, a 90 year-old resident of Milford Grange aged care home, has mobility issues and is unable to travel to the GP. She has chronic health conditions, necessitating regular appointments with her GP. Betty has been unable to drive for the past 15 years and finds it too challenging and confronting to use taxis to travel to appointments. The new Visionflex telehealth equipment can be used by Betty (and others at Milford Grange) to facilitate easy access to GP appointments from the comfort of their own homes. It enables the health conditions of Betty and the retirement village residents to be monitored and managed in a timely manner, optimising their health and wellbeing. A similar benefit is being felt by Clifton Medical Practices, who we supplied with a Visionflex Cart as well.
It allows all interactions between patients and Dr Fang Wei Chen to be recorded. Dr Chen reflected on the opportunity to use the stateof-the-art technology, saying:
“I am so happy to be able to part of this solution to meet the health needs of the local community. I have a passion for rural health care, but my family commitments mean I need to stay in the city. This project enables me to have the best of both worlds.” Interim Practice Manager, Anne-Marie Donovan said:
“We are so excited to use this technology with our patients. The opportunity for our GPs to have a highquality consultation from anywhere in the world with an internet connection opens so many opportunities for both our patients and our GPs.”
The Visionflex operating at Clifton Medical Practices.
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 50
Healthy primary care
AFTER HOURS SERVICES
35
22,705
practices providing funded services
after hours consultations
We have continued our work in this area from last year, offering support and practice performance tools for general practices to extend their opening hours into the after-hours period. These extended hours will enable GPs to address the additional demands being experienced across the health system and our communities through increasing appointment availability for working-age people in the region
The GP After Hours Support Program has played a crucial role in addressing community needs, including long wait times; inaccessible preventative health care for the cohort who work during standard business hours; and unsustainable emergency department presentations.
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 51
Healthy primary care
STAFF SPOTLIGHT Rebecca Cerqui Primary Care Liaison Officer What is your role with the PHN? Primary Care Liaison Officer For you, what is the best thing about working for the PHN? The best thing about working at the PHN is that it provides an opportunity to work with the different PHN teams on a wide variety of projects, all contributing to improving the health outcomes of the community. It is rewarding seeing the various planned programs come to fruition, and the positive impact they make on the region. It is also so great working with such a terrific group of people every day! What are you most proud of achieving in the 2022/23 FY? It was exciting launching the Allied Health Engagement strategy and implementing some of the early activities outlined in the strategy, for example networking events and the Allied health development grant. The grants provided to Allied health professionals are being put towards some innovative and impactful projects, and it is exciting to see these activities be carried out!
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 52
Healthy partnerships
Healthy partnerships
Collaborating effectively, with a one system mindset.
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 53
Healthy partnerships
WEST MORETON HEALTH
DARLING DOWNS HEALTH
Collaboration and integration is at the core of the work we do in our region, and a key component of our strategic plan.
Jointly covering a large rural region, the PHN and Darling Downs Health work closely together to ensure our wide spread and diverse community members have access to high quality health care.
In particular, the working relationship between PHNs and their Hospital and Health Services counterparts is paramount to achieving a more connected health system. We have a formalised agreement in place with West Moreton Health, and informally work together on a weekly basis across many local initiatives. Two such programs are: •
‘Healthy Minds, Healthy Lives’ initiative
•
West Moreton Care Collaboratives
Joint initiatives include: •
‘Healthy Minds, Healthy Lives’ initiative
•
Darling Downs Care Collaboratives
•
Goondiwindi Cross Border initiative
•
Cherbourg Health Council
•
Rural health workforce
•
people will be able to attend a Medicare UCC for non-life threatening acute episodic care for minor injuries and illnesses. This includes closed fractures, simple eye injuries, minor burns, treating a UTI or ear infection.
MEDICARE URGENT CARE CLINICS As part of the 2023-24 Budget announcements in May, the Australian Government committed $358.5 million over five years from 2022-23 to establish 58 Medicare Urgent Care Clinics (Medicare UCCs) across Australia. The Medicare UCCs are a new model of care to reduce pressure on our hospitals. They will provide bulk-billed, culturally safe, equitable and accessible urgent care to all people, including vulnerable and young people. Medicare UCCs will: •
be based in existing GP clinics, community health centres and Aboriginal Community Controlled Health Services
•
be open after normal business hours and accept walk-in patients
•
be diverse, responding to the needs of the local community
•
be accessible to all people, including vulnerable people and young people.
The Darling Downs and West Moreton PHN region has received funding for two Medicare UCCs – one in Ipswich and one in Toowoomba. This year, we kick-started the selection process for both the Ipswich and Toowoomba Medicare UCCs, with plans to have both clinics operational before November, 2023. This has involved establishing a cross-functional team with representatives from West Moreton Health, Queensland Ambulance and general practice, to oversee the in-depth selection process. Collaboration between the PHN and the respective Hospital and Health Services is a key component, with the integration of a Medicare UCC with the local Emergency Department a critical part of how it will operate.
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 54
Healthy partnerships
‘HEALTHY MINDS, HEALTHY LIVES’ PARTNERSHIP The challenges our community and our health system have faced over the past few years are considerable and the impact on our collective mental health has been significant. To make a difference, we need to work together, and it is in this spirit that we have worked with West Moreton Health and Darling Downs Health to refresh and refocus ‘Healthy Minds, Healthy Lives’ – our comprehensive Joint Regional Mental Health, Suicide Prevention and Alcohol and Other Drug Plan.
‘Healthy Minds, Healthy Lives’ is the result of extensive consultation with a range of stakeholders, including people with lived experience, service providers, clinicians and community stakeholders, and the strong partnership between West Moreton Health and Darling Downs Health and our PHN.
‘Healthy Minds, Healthy Lives’ continues and builds upon the development and implementation from previous planning. It provides a shared vision and approach, setting our collective goals and aspirations for making a difference for people living with mental health conditions and alcohol and other drug use, and their families.
WEST MORETON CARE COLLABORATIVES The West Moreton Care Collaboratives (WMCC) is a project funded by our PHN and overseen by the University of Southern Queensland in support of older persons’ health. WMCC is a collective project spanning two initiatives: the Care at the End of Life (CAEOL) Collaborative, established in July 2018, and the West Moreton Older Persons Care (OPCC) Collaborative, which was established in February 2021 following the success of the CAEOL Collaborative. This year, the WMCC brought together health professionals and consumers to explore health solutions for a rapidly ageing population through the West Moreton Care Collaboratives Symposium and Expo, which took place in November.
Community members from across West Moreton were invited to attend the free community expo, which hosted over 30 health services and providers. University of Southern Queensland nursing students were also in attendance to assist with health-related questions and provide free health assessments to visitors. The symposium section of the event provided attending health professionals with a full day of educational sessions on a variety of topics including voluntary assisted dying (VAD), human rights and elder abuse, delirium, dementia and depression, trauma-informed care and older people, exercise and brain health, selfmanaged aged care and oral health and hygiene.
PHN staff Erica Newman, Tamara Williams, Denise Pambid, Christine Gallagher and Lindi Mpala at the Symposium.
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 55
Healthy partnerships
GOONDIWINDI CROSS-BORDER INITIATIVE Goondiwindi is a regional town situated four hours inland from Brisbane, on the border of Queensland and New South Wales. As a result, the local health system relies on close coordination between the state health departments, primary care, and the community to achieve equitable access to healthcare for residents on both sides of the border. During the year, we partnered with local health providers to improve health equity in the Goondiwindi region. In early December, we hosted a cross-border meeting that was attended by over twenty health professionals from the surrounding area. Topics included improved cross-border information sharing, improving access to transport, increasing access to allied health and dental, and various other opportunities to help connect the local health system. The cross-border meeting was highly successful, with our CEO acknowledging that the health system in the Goondiwindi area is complex, but how it is affirming to have the dedication of local health professionals who share our focus on improving health equity for the area. Our work in Goondiwindi is particularly focused on improving health equity for the nearby towns of Toomaleh, a local Aboriginal community and former mission, and Boggabilla, which has a predominately Indigenous population. Both towns lay just beyond the New South Wales border within the local Goondiwindi area.
DETERMINANTS OF CANCER SCREENINGS PARTICIPATION IN QUEENSLAND: A SCOPING REVIEW
QAS DIVERSION In December, the Darling Downs and West Moreton PHN was funded by the West Moreton Hospital and Health Service to seek applications from West Moreton general practices and Aboriginal Medical Services who were interested in participating in a project working with the Queensland Ambulance Service (QAS) and the Ipswich Hospital Emergency Department (ED). The program, which went live on 23 January 2023, supported the treatment of primary care appropriate patients located in the West Moreton Local Government Area who contacted the QAS for assistance with conditions that could be best treated in the primary care setting. The program ran until May 2023, and made 50 successful referrals. These referrals reduced avoidable Ipswich Hospital ED presentations to facilitate improved access to care and patient flow. Through multi-agency collaboration, the PHN facilitated rapid project development, signing contracts with four clinics within the area, and providing training. Additionally, agreements with transport providers were in place for return home journeys, and priority processes in place for patients arriving at general practice clinics via their own transport. Patient satisfaction with the service was high, with those surveyed indicating they felt safe, involved, and listened to. GP evaluations indicated the program was smooth and worked well, with most referrals appropriate. With Medicare Urgent Care Clinics opening in our region during the next financial year, the learnings from these evaluations will be put to good use in developing robust referral protocols between QAS and the Medicare UCCs.
In May, a scoping review written by members of the Darling Downs and West Moreton PHN’s digital transformation, performance and evaluation team was accepted and then published in the Journal of Primary Health Care (JPHC) in early July. The review article provided an overview of the literature regarding the determinants of cancer screening participation among target groups in Queensland. Its results cited that encouragement from health professionals, providing more information and interactions with communities would result in different effects on cancer screening participation among the target groups. The JPHC publishes peer-reviewed original research and systematic reviews and papers on improving performance that are relevant to its primary health care audience. You can read the full article through the CSIRO website.
LEARN MORE www.publish.csiro.au/HC/HC23012
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 56
Healthy partnerships
CLINICAL COUNCIL The Clinical Council plays an important role in providing advice on locally relevant clinical matters.
Our Clinical Council members are: •
Dr Tony Bayliss: PHN Chair and GP
•
Dr Andy Mellis: Clinical Council Chair and GP
•
Tamika Campbell: Deputy CEO - Carbal
•
Dene Creegan: Practice Manager
•
Dr Meech Freeman: A/Clinical Director Rural Health – West Moreton Health
•
Dadirai Gara: Psychologist
•
Simone Karandrews: Sonographer and Community Advisory Council Representative
•
Rica Lacey: Director Indigenous Health – Darling Downs Health
•
Wendy Owen: Speech Pathologist
•
Judith Pasco (France): Podiatrist
•
Six West Moreton and six Darling Downs representatives
Dr Vishwas Raghunath: Nephrologist/ Obstetric Physician
•
Elise Stevenson: Registered Nurse
•
Four doctors
•
Darling Downs Health GPLO: Ex officio
•
One practice manager
•
West Moreton Health GPLO: Ex officio
•
Four allied health
•
One registered nurse
•
One Director Indigenous Health
•
One GM Aboriginal Community Controlled Health Organisation
•
One representative each from West Moreton Health and Darling Downs Health
With the Federal Government focus on primary care, including the Strengthening Medicare Taskforce and the Ten-Year Primary Care Plan, the Clinical Council supports collaboration as well as advocate, promote and encourage engagement across the healthcare system. A review of Clinical Council membership earlier this year identified that we needed to strengthen and refresh our Council. We therefore updated the terms of reference to better reflect the Clinical Council’s role in the PHN, including a focus on a strengths-based approach and called for re/new membership through an expression of interest. Broader membership was actively encouraged, particularly from a range of diverse health disciplines. The membership includes: •
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Healthy partnerships
COMMUNITY ADVISORY COMMITTEES The role of the Community Advisory Committees is to provide the community perspective to PHN Boards to ensure that decisions, investments, and innovations are patient centred, costeffective locally relevant and aligned to local care experiences and expectations. PHNs are expected to ensure that Community Advisory Committee members have the necessary skills to participate in a committee environment and are representative of the PHN. To meet this requirement, we have two Community Advisory Committees in place; one in West Moreton and one in Darling Downs, each with up to nine members plus the Chair (Board representative) A review of the membership earlier in the year identified that we needed to strengthen and diversify our Community Advisory Committees. We updated the terms of reference to better reflect the CAC role in the commissioning framework and called for new membership through an expression of interest.
Darling Downs: •
Dr Graham McAllister: Chair
•
Elizabeth Adams: Co-chair
•
Anya Smith: Community Representative
•
Bradley Jones: Community Representative
•
Bree Manning: Community Representative
•
Elizabeth Kerrison: Community Representative
•
Louise Judge: Community Representative
•
Rochelle Jesser: Community Representative
West Moreton: •
Professor Lauren Ball: Chair
•
Ellisha Freeman: Community Representative
•
Kim Stanton: Community Representative
•
Leonie Short: Community Representative
Twelve applications were received – six for Darling Downs and six for West Moreton – with an Aboriginal and/or Torres Strait Islander person nominating for each committee.
•
Michael Winton: Community Representative
•
Simone Karandrews: Community Representative
Our Community Advisory Committee members are:
•
Uncle Milton Walit: Community Representative
TALK ABOUT Our PHN’s TALK ABOUT initiative is an ongoing engagement project that facilitates the valuable role of community input, advice and informs our shaping of effective, accessible and high-quality local health services. TALK ABOUT is a unique initiative, conceived of and developed by our PHN. It is an innovative model, originally introduced in early 2020 to add value and complexity to the PHN’s Health Needs Assessment publication. In the three years since, the PHN has engaged the community on 14 health topics and has heard from over 2,200 people. TALK ABOUT is run region-wide to reach a diverse range of community members with a new topic covered every three months. Each topic involves an online survey and a series of Kitchen Table Discussions. This format has been developed to maximise reach within the community, with the goal of engaging with people in priority health populations who may have reduced trust in the system or low levels of access due to factors such as travel cost, internet access or disability access requirements.
The online surveys are short, anonymous, and designed to gather insights around ‘what is working well’ and ‘what could be done better’. The Kitchen Table Discussions are facilitated by community hosts without the presence of a PHN staff member to ensure participants feel safe to share their experiences, ideas and advice. This year, we engaged with 925 people across the following topics: •
Aboriginal Health (September)
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Allied Health (December)
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Digital Health (April)
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Alcohol and Other Drugs (June)
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 58
LEARN MORE ddwmphn.com.au/Talk-About
Healthy partnerships
STAFF SPOTLIGHT Max Millis Communications Officer What is your role with the PHN? My role is to promote the PHN’s position within the health care sector and to inform our communities and stakeholders about services and programs offered by the PHN and the wider healthcare sector. My role includes publications such as our monthly PHN News, social media, and alerts to our GPs and allied health to ensure our primary health care system remains connected. For you, what is the best thing about working for the PHN? Coming to the PHN straight out of uni, where I completed a Bachelor of Public Health/Bachelor of Media and Communication, has been an opportunity to combine two of my greatest passions: healthcare and communications. One of my favourite aspects of the PHN is the strong workplace culture, where we value innovation and collaboration and share a common belief that we can make a positive impact to the health outcomes in our community through implementing these values in our work. What are you most proud of achieving in the 2022/23 FY? I really enjoyed producing the monthly PHN News. These articles are a great avenue for reflecting on the successes of the PHN and our stakeholders in our approach to improving primary healthcare in our region. I was proud to be involved in the communications for the ‘Connected Health Care Grants’ which will enable our practices to adopt digital health technology, ensuring rural communities have access to quality care through remote monitoring, consultations and treatment using telehealth. I have also enjoyed facilitating the Project ECHO Older Persons Series in 2023.
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 59
E: info@ddwmphn.com.au
Darling Downs
West Moreton
P: 07 4615 0900
Level 1, 162 Hume Street (PO Box 81), Toowoomba QLD 4350
Level 5, World Knowledge Centre, 37 Sinnathamby Boulevard, Springfield Central QLD 4300
W: www.ddwmphn.com.au
Darling Downs and West Moreton PHN Annual Report 2022-2023 | page 60
ABN 51 605 975 602