Eastern sydney medicare local annual plan 2014 5 by Eastern Sydney ML

Schedule 21.1 REGIONALLY TAILORED PRIMARY HEALTH CARE INITIATIVES THROUGH MEDICARE LOCALS FUND

2014-15 Annual Plan

Medicare Local Name

EASTERN SYDNEY

CEO

SHONA DUTTON

Phone:

(02) 9663 5958

e-mail:

dwilliams@esml.org.au

Contact Person

NEIL WILLIAMS

Phone:

(02) 9663 5958

e-mail:

nwilliams@esml.org.au

Date Submitted

16th May 2014

In submitting this Annual Plan to the Department of Health, the Medicare Local has ensured that all internal clearances have been obtained and the Annual Plan has been endorsed by the CEO and any other appropriate personnel and/or Board members.

Eastern Sydney Medicare Local 2014-15 Annual Plan

Glossary Activity Identified Need Strategy

Resourcing

Region Strategic Objective (SO)

Key Reporting Area (KRA) Fund Priorities (FP)

The action(s) undertaken to implement the strategy The issue(s)/need(s) that have been established as priorities to address in Table 6 of the Comprehensive Needs Assessment Reporting Template The approach/intervention/initiative chosen to address the identified need in Table 6 of the Comprehensive Needs Assessment Reporting Template The indicative proportion of funding allocated to the activity from the overall funding provided under Schedule 21.1 for 2014-15. This must be GST exclusive The region in which the activity is being delivered. This could be the whole Medicare Local region or a sub-region The Five Medicare Local Strategic Objectives outlined in Schedule 1.1 of the Medicare Local Deed for Funding and Medicare Local Operational Guidelines The Six Key Reporting Areas outlined in the Medicare Local Operational Guidelines The Six Flexible Fund Priorities outlined in the Flexible Fund Guidelines for the Regionally Tailored Primary Health Care Initiatives through Medicare Locals Fund

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Eastern Sydney Medicare Local 2014-15 Annual Plan

Strategic Directions Strategic Objective 1 – Improving the patient journey through developing integrated and coordinated services

Strategic Objective 2 – Provide support to clinicians and service providers to improve patient care



Continue to develop and implement models of integrated care within targeted areas within the community to support identified priority areas including referral pathways and workforce/capacity deficiencies;



Continue to implement evidence based, collaborative approaches to integrated care through referral pathways and/or service networks

Provide requisite resources to support models of integrated care via:  General Practice Support Program  Allied Health Support Program  Delivery of relevant CPD, either directly or in partnership with key stakeholders  Credentialing of local services providers to facilitate inclusion in local service directory.

Strategic Objective 3 – Identification Comprehensive Needs Assessment completed May 2014 of the health needs of local areas identifies regional health needs and serves as the basis of all and development of locally focussed 2014-15 planning and resources allocation. and responsive services

Strategic Objective 4 – Facilitation of the implementation and successful performance of primary health care initiatives and programs



Strategic Objective 5 – Be efficient and accountable with strong governance and effective management

Enhance community based projects to address the identified health priorities and/or prevalent population groups; o Lifestyle risk factor management - Overweight, obesity, nutrition and physical activity (HEAL, ComDiab and Counterweight) o People aged 65 years or older (aged care, falls prevention, medication management, depression, loneliness, grief and dementia) o Pulmonary disease prevention and management (Lungs in Action) o Diabetes prevention and management (ComDiab, HEAL and Counterweight) Enhance existing projects to support identified health priorities and/or prevalent population groups; o Chronic disease management - Care Navigation and Connecting Care o Aboriginal and Torres Strait Island Communities with chronic disease – Care Coordination and Supplementary Services

ESML’s effective governance model is built upon:  

A skills-based Board; An organisational structure and leadership group held accountable for program delivery and effective

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Eastern Sydney Medicare Local 2014-15 Annual Plan

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management of the organisation; Building on the positive impacts of a successful Accreditation process, continue to refine and implement appropriate quality management systems and knowledge management processes.

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Activities Table [1] ACTIVITY NAME

Integrated care - Model of integrated care

IDENTIFIED NEED



STRATEGY

Continue to implement models of integrated care within targeted areas within the community to support identified priority areas including referral pathways and workforce/capacity deficiencies Continue to implement the following activities supporting integrated care in the community;  Chronic disease prevention and management programs  Aged Care programs  ESML GP and AHP Support Programs  Connecting Care  Care Navigation  ATAPS  Partners in Recovery (PIR)

Description

SO 1, 2

KRA 1,3

FP 1-3

Provide clear referral pathways to improve the care coordination for primary care providers

Chronic disease prevention and management Continue to implement community based programs to treat and manage increasing rates of modifiable chronic disease through lifestyle risk factor management. The following programs will be established and form part of the integrated referral pathways activity;  ComDiab diabetes education program  Healthy Eating & Active Lifestyle (HEAL) Program  Counterweight  Lungs in action Aged Care  Continue to implement the established aged care programs to support people aged 65 years and older living in the community and local residential aged care facilities. These programs include;; o The falls prevention physical activity program designed to enhance strength and conditioning of consumers. The program will be led by allied health professionals and be delivered to targeted community members and residents of local aged care facilities o Actively promote activities to enhance the role of GPs in medication management, prescribing and polypharmacy for people aged 65 years or older. Activities will include; o Promote HMRs and ePrescription, and develop and implement,

Eastern Sydney Medicare Local 2014-15 Annual Plan o

Quality improvement activities to focus on GP prescribing habits specifically for benzodiazepines and opioids o Facilitate implementation of eReferral, eTransfer, eDischarge and ePrescriptions for residents of aged care facilities with local hospitals Continue to implement the established psychological counseling sessions for residents in RACFs. The program links qualified allied health providers with people aged 65 years or older living in the community or RACFs, with depression, loneliness and grief

ESML GP and AHP Support Programs Continue to implement the established ESML General Practice and Allied Health Support Programs to ensure local primary health care providers have access to up-to-date information regarding the abovementioned programs Connecting Care Continue to implement the established Connecting Care program in collaboration with the SESLHD. The program will be linked with other activities to ensure integration, use of referral pathways and focus on equitable access to health service providers ATAPS Continue to implement the established ATAPS mental health program. The program will be linked with other activities to ensure integration, use of referral pathways and holistic care for patients with mental health Partners in Recovery (PIR) Continue to implement the established Partners in Recovery (PIR) Program in collaboration with consortium members. The program will be linked with other activities to ensure integration, use of referral pathways and focus on equitable access to for consumers Type of activity

Strategy will include the following types of activities;  Service delivery (clinical and non-clinical)  Commissioning service delivery (clinical and non-clinical)  Engagement  Planning and evaluation  Education and training

Region

ESML region

Sector



All primary health care providers servicing the region including but not limited to; GPs, Practice Nurses, Practice

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Eastern Sydney Medicare Local 2014-15 Annual Plan

 

Service Provider

 

Performance information



Expected outcome

       

Staff, Allied Health Professionals, Local Hospital Network representatives, Local Hospital District Representatives, Medical Specialists, Pharmacists, Dentists, Optometrists, mental health service providers and residential aged care facilities Community members and community representative groups including minority or marginalised groups such as Aboriginal and Torres Strait Island community, people aged 65 years or older, multicultural groups, LBGTI groups Relevant government/non-government, social, welfare and charitable service providers such as; culturual groups, Aboriginal and Torres Strait Island community groups, local councils, homeless services, drug and alcohol, housing and community services, police and corrective services. It is anticipated that ESML will be responsible for coordinating and facilitating each of the activities outlined in this strategy Service delivery for programs will be provided in part by ESML and in part commissioned using services of community based primary health care professionals such as allied health Continue to facilitate projects to address the identified health priorities and/or prevalent population groups; o Lifestyle risk factor management - Overweight, obesity, nutrition and physical activity (HEAL, ComDiab and Counterweight) o People aged 65 years or older (aged care, falls prevention, medication management, depression, loneliness, grief and dementia) o Pulmonary disease prevention and management (Lungs in Action) o Diabetes prevention and management (ComDiab, HEAL and Counterweight) o Chronic disease management - Care Navigation and Connecting Care o Aboriginal and Torres Strait Island Communities with chronic disease – Care Coordination and Supplementary Services o Mental Health – Partners in Recovery and ATAPS Increased access to services contributing to multidisciplinary care in the region Improved navigation of primary health care services in the region for identified community members and stakeholders Enhanced capacity to manage the lifestyle risk factors of local community members Increase patient and stakeholder literacy regarding pathways and management of identified health conditions Enhanced communication between members of the primary health care and multidisciplinary team Comprehensive education and training calendar for 2014-15 period including multidisciplinary models of care Increased number of holistic care providers participating in ESML education and training Increased understanding of barriers, limitations and enablers to primary health care service provision in the region

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Eastern Sydney Medicare Local 2014-15 Annual Plan [2] ACTIVITY NAME

Integrated care – Referral Pathways

IDENTIFIED NEED

Provide clear referral pathways to improve the care coordination for primary care providers

STRATEGY

Continue to implement evidence based collaborative approaches to integrated care relevant to the ESML population health profile.  Continue to implement evidence based collaborative approaches to integrated care relevant to the ESML population health profile. Considerations to include the following essential elements of integrated care principles; o Clinical protocols and care packages o Care coordination and planning including defining systems of care (pathways) o Defining and awareness raising of professional scope of those involved with care of patients – considering a holistic approach o Case conferencing o Performance review Holistic approach to patient treatment/management such as social, welfare and psychological considerations

Description

SO 1, 2

KRA 1-6

FP 1,2, 5,6

Integrated care models  Continue to establish the following models of integrated care across the region;; o Extend the existing Care Coordination/Navigation Programs o Ensure a focus on chronic and complex medical conditions including; mental health, homelessness and drug and alcohol conditions o Engage relevant stakeholders to capture detailed information regarding barriers, limitations and enablers to implementation of referral pathways e.g. on-site visits with representatives from HealthPathways Australia.

Type of activity

Support Continue to implement referral pathways initiative;  Update the ESML Community and Stakeholder Engagement Plan to support the implementation of each initiative  Update the ESML Marketing and Communications Plan to support the implementation of the initiative  Implement education and training to be delivered to support uptake of the initiative amongst local providers  Support implementation via the ESML GP and AHP Support Programs Strategy will include the following types of activities;  Continue to engage with key stakeholders to support delivery and evaluation of models including: LHN, LHD, AHPs and other relevant providers  Education and training

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Eastern Sydney Medicare Local 2014-15 Annual Plan  

Marketing and communications Re-defining care pathways including new models of care

Region

Sector

ESML region

Service Provider



All primary health care providers servicing the region including but not limited to; GPs, Practice Nurses, Practice Staff, Allied Health Professionals, Local Hospital Network representatives, Local Hospital District Representatives, Medical Specialists, Pharmacists, Dentists, Optometrists, mental health service providers and residential aged care facilities



Performance information

     

Expected outcome

 

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Eastern Sydney Medicare Local 2014-15 Annual Plan [3] ACTIVITY NAME

PHC Workforce Development

SO 1-4

KRA 1,3,4

IDENTIFIED NEED



STRATEGY

Implement strategies to address growing primary care service demand – PHC workforce enhancement strategies, outreach services for identified disadvantaged regions around priority health conditions

Description

Develop an implementation plan to implement the following activities;  Environmental scanning  Succession planning  Capacity building  Workforce recruitment

FP 1,2, 5

Environmental scanning  Establish comprehensive environmental scanning activities regarding workforce in identified regions of growth. Outcomes to identify; o Demographic and professional profile of local health care professionals in the region relevant to workforce sustainability e.g. FTE, Age, hours of operation, gender o Priority professions required for regions o Specific disease prevalence issues o Specific areas of need (geographical) o Potential strategies o Opportunities for collaboration and integration o Identify integrated care networks e.g. co-locate in pharmacy/community centre o Outline role of eHealth Succession Planning Develop education activities and resources to support PHC providers with workforce succession planning with the SESLHD and activities to support primary health care providers aged 50 years and over to plan for continuation of their business. Activities to include;  Sourcing appropriate successor(s)  Safeguard the practice legacy Communicating arrangements to patients Capacity building Working with providers to enhance the capacity of existing primary health care services to generate efficiencies in

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Eastern Sydney Medicare Local 2014-15 Annual Plan provision of care. Activities to include;  Ensure consideration and application of relevant eHealth initiatives such as data cleaning, software use and conformity, secure messaging, PCEHR, directories of providers and secure messaging addresses  Application of eHealth initiatives within prevalent diseases (in line with needs)  Continue to implement the ESML GP and AHP support programs  Establish models of integrated care for targeted areas within the community to support identified priority areas and enhance capacity of existing service providers and reduce need for services. Refer to Activity 1 of this plan for further details 



Aged care programs such as falls prevention, medication management and access to psychological services (outlined in more detail in Integrated care (model of integrated care) o Connecting Care o Care Navigation o ATAPS o Partners in Recovery (PIR) Work in collaboration with stakeholders such as LHD and SVH D & A services to develop and implement outreach services focusing on areas of need

Workforce recruitment strategy  Work with key stakeholders such as local Councils, Local Hospital District, Local Hospital Network, local Universities, and Peak Training bodies to generate clinical recruitment activities. Professions to be targeted include; practice and community nursing, allied health professionals, social and welfare service providers  s to support workforce strategies e.g. co-location of services  Develop PHC capacity building strategy/plan to enhance teamwork and team links in PHC e.g. tools for referral (eHealth), enhancing the role of non-clinical staff, awareness raising around systems of care  Develop education and training activities related, focusing on prevalent conditions, team work and team links  Implement a marketing and communications plan in line with new approaches outlined within this activity. Focus on dissemination strategies such as website, print, media, face-to-face delivery of resources e.g. PSO Type of activity

Strategy will include the following types of activities;  Engagement with key stakeholders  Establishing formal partnerships with key stakeholders (LHN, LHD and relevant providers)  Education and training  Marketing and communications  Service delivery (clinical and non-clinical)  Commissioning service delivery (clinical and non-clinical)

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Eastern Sydney Medicare Local 2014-15 Annual Plan

Region

Identified regions of growth including; Mascot, Rosebery and Botany

Sector

ESML region

Service Provision



Relevant government/non-government, social, welfare and charitable service providers such as; culturual groups, Aboriginal and Torres Strait Island community groups, local councils, homeless services, drug and alcohol, housing and community services, police and corrective services. Establish comprehensive environmental scanning activities regarding PHC workforce needs in identified regions of growth Establish models of integrated care for targeted areas within the community to support identified priority areas and enhance capacity of existing service providers and reduce need for services Establish partnership with South Eastern Sydney Local Hospital District and St Vincent’s Drug and Alcohol Services with formal terms of reference Implement joint activities to address alcohol and medication management to increase capacity of local primary health care providers in managing patients in need of these services Work collaboratively with primary health care peak bodies, training and professional development organisations to identify and implement strategies for clinician recruitment Develop and implement a comprehensive strategy to deliver direct support local primary health care providers using the following ESML resources; o Practice Support o Network Support Program o Continuing Professional Development (CPD) o Quality Improvement Program NB: Activities to focus on capacity building to generate efficiencies within service delivery

Performance information

     

 

Establish and implement an explicit organisation wide stakeholder engagement plan and marketing communications plan for the 2014-15 period, aligning with strategic priorities and key reporting areas. Integration of relevant eHealth initiatives within all activities including; registration to secure messaging and PCEHR for new providers

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Eastern Sydney Medicare Local 2014-15 Annual Plan Expected outcome

  

Increased understanding of specific workforce requirements for identified regions including; priority professions, specific disease prevalence issues, opportunities for collaboration and potential strategies Increased engagement and collaboration with primary health care peak bodies, training and professional development organisations to identify and implement strategies for clinician recruitment Increased efficiency in the delivery of primary health care services in identified areas of need/growth

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Eastern Sydney Medicare Local 2014-15 Annual Plan [4] ACTIVITY NAME

Integrated care – Holistic care

IDENTIFIED NEED

Encourage a holistic approach for people experiencing severe mental illness

STRATEGY

Support a holistic approach to primary health care including social, welfare considerations. Specifically for people experiencing severe mental illness. Service mapping and education  Comprehensively map holistic care providers servicing the region, including social, welfare and charitable providers.  Develop and implement a comprehensive, multidisciplinary education and training model, underpinned by holistic care philosophy for community and stakeholders, inclusive of mapped service providers  Develop and implement marketing and communications plan using a range of mediums to target a broad range of providers to reinforce a ensure holistic approach

Description

SO 1, 2

KRA 3

FP 1,2,5

Provision of outreach services; Link holistic care strategy with the following ESML activities;  Workforce development strategy  Alcohol and medication management  Incorporate principles of ‘Recovery’ within mental health initiatives, specifically Partners in Recovery program  Models of integrated care  Alcohol and prescription medication management  Consumer literacy  ESML GP Practice Support Program  ESML Allied Health Support Program Enhanced communication mechanisms to ensure meaningful and timely patient management  Ensure a range of support, communication tools, and resources are implemented with meaningful communication with a broad range of holistic care providers including; o ESML Practice and Network Support programs to support implementation of multidisciplinary care across the spectrum of primary, secondary and tertiary care o Ensuring continued implementation and enhancement of eHealth initiatives o Detailed and clinically focused referral pathways o ESML models of integrated care such as Counterweight, ATAPS, ComDiab and Connecting Care

Type of activity

Strategy will include the following types of activities;

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Eastern Sydney Medicare Local 2014-15 Annual Plan   

Engagement with holistic care providers Establishing formal partnerships with key stakeholders (LHN, LHD and relevant providers) regarding provision of holistic care Planning and evaluation

Region

ESML region

Sector



Service Provider Performance information

Expected outcome

Relevant government/non-government, social, welfare and charitable service providers such as; culturual groups, Aboriginal and Torres Strait Island community groups, local councils, homeless services, drug and alcohol, housing and community services, police and corrective services. It is anticipated that ESML will be responsible for coordinating and facilitating each of the activities outlined in this strategy  Comprehensive mapping of broad range of service providers relevant to holistic care of prevalent medical conditions across the region  Number and type of education and training opportunities provided including holistic approaches to primary health care  Number and type of outreach services implemented with holistic care integrated  Number and type of communication mechanisms and/tool implemented to ensure meaningful and timely patient management  Number completed patient experience questionnaires  Captured a detailed map of a broad range of holistic care providers for the region  Comprehensive education and training calendar for 2014-15 period including multidisciplinary models of care, opportunities for networking and collaboration and focusing on a broad range of (holistic) care providers  Identification of collaborative opportunities or care providers including holistic care providers e.g. referral pathways  Increased number of holistic care providers participating in ESML education and training  Increased understanding of barriers, limitations and enablers to primary health care service provision in the region

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Eastern Sydney Medicare Local 2014-15 Annual Plan [5] ACTIVITY NAME

Childhood Immunisation Support

IDENTIFIED NEED

Improve childhood immunisation rates specifically focusing on Woollahra, Waverley

STRATEGY

Strategy to provide intensive and individually tailored responses for general practices with high rates of unvaccinated children across the region. The activity will work collaboratively with the general practice support program to provide sustained support for local general practices regarding immunization. The description section of this plan defines how the two approaches will work together to address childhood immunization for the ESML region. ESML capacity Determine the internal (ESML) capacity requirements to adequately resource this strategy using a cross-organisation approach to support the following elements of this strategy, outlined below;

Description

SO 2

KRA 2

FP 5

Intensive Strategy  Liaise with PHU regarding immunisation strategy  Horizon scanning, data analysis  Liaise with PHU to identify unvaccinated children across region  One-to-one training with general practices using identified patient data to complete the following; o Data cleaning o Recall unvaccinated children o Update inaccurate practice records o Update inaccurate Australian Childhood Immunisation Register data including children that have relocated o Systems/processes for implementing vaccinations amongst children in the practice o Processes for reporting/communicating with ACIR o Identify barriers and limitations

Type of activity

General Practice Support Immunisation Program  Education, training and resources to support all local general practices complete comprehensive immunization of all children will be implemented via the ESML Practice Support model. General Practice Support Program Officers will disseminate the abovementioned for the following areas; o Systematic implementation of immunisation (R & R, appointment systems, billing, use of PN) o Reporting to ACIR o Education regarding benefits of immunisation o Vaccine storage o Identify barriers and limitations Strategy will include the following types of activities;

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Eastern Sydney Medicare Local 2014-15 Annual Plan Education, training and capacity building within targeted general practices and amongst local general practitiioners, practice nurses and practice staff Region

ESML region

Sector

  

Service Provision Performance information

Representatives from the South Eastern Sydney Local Hospital District Public Health Unit General Practice including; GPs, Practice Nurses and Practice Staff Community members from local community groups representative of the targeted childhood immunization age groups It is anticipated that ESML will be responsible for facilitating each of the activities outlined in this strategy   



 

Expected outcome

Establish partnership with SESLHD Public Health Unit with formal terms of reference Implement joint activities to enhance immunisation rates across the region Improvements in childhood immunisation coverage rates within ESML for the following target groups; o % for 12-15 month old children o % for 24-27 month old children o % for 60-63 month old children Improvements in coverage rates for the following targeted regions; o Woollahra o Waverley Number and type of education material/support resources disseminated to community and stakeholders e.g. Immunisation Schedule Handbooks Number and type of episodes of support provided to local general practices by ESML e.g. Data cleaning and accuracy, reporting to ACIR vaccine



Implement a coordinated approach to immunisation support implemented in partnership with SESLHD Public Health Unit  Improvements in childhood immunisation coverage rates within ESML for the following target groups in Woollahra and Waverley Local Government Areas; o % for 12-15 month old children o % for 24-27 month old children o % for 60-63 month old children  Increased literacy regarding NSW immunization schedule, processes, reporting procedures and systems amongst local community members, and general practices  Established a comprehensive range of resources to support consumer and provider literacy regarding

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Eastern Sydney Medicare Local 2014-15 Annual Plan

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Eastern Sydney Medicare Local 2014-15 Annual Plan [6] ACTIVITY NAME

Consumer and provider health literacy and support

SO 3,4

KRA 3,4

FP 1,5

IDENTIFIED NEED

Empower consumers by providing more detailed information regarding available services .e.g. Increase awareness & availability of GP specialties, consumer and provider health literacy

STRATEGY



Description

Develop and implement a comprehensive health literacy program to enhance knowledge, understanding and access to best practice, quality health related information Health literacy Focus will be on; o Consumer health literacy regarding local health priorities o Consumer literacy regarding access to health information including role and professional scope of PHC providers o PSC and AHP direct service support o Stakeholder literacy regarding local health priorities and pathways available o Stakeholder literacy regarding access to health information including role and professional scope of PHC providers, referral pathways or systems of care, access information o eHealth resources relevant to consumers and prevalent chronic conditions – benefits of participation etc. Evaluation of patient journey  Patient experience questionnaire  Research regarding perceptions, literacy of childhood immunisation in the region  Community satisfaction – eHealth, CCSS, CC, MH, HEAL, Counterweight, Walking groups, Aged Care programs  Provider satisfaction – CPD, literacy around health priority areas, governance groups

Type of activity

 Strategy will include the following types of activities; • Stakeholder engagement with key stakeholders • Establishing formal partnerships with key stakeholders (LHN, LHD and relevant providers) • Education and training • Marketing and communications

Region

ESML region

Sector



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Eastern Sydney Medicare Local 2014-15 Annual Plan 

Service Provider Performance information

Expected outcome

Community members and community representative groups including minority or marginalised groups such as Aboriginal and Torres Strait Island community, people aged 65 years or older, multicultural groups, LBGTI groups  Relevant government/non-government, social, welfare and charitable service providers such as; cultural groups, Aboriginal and Torres Strait Island community groups, local councils, homeless services, drug and alcohol, housing and community services, police and corrective services. It is anticipated that ESML will be responsible for coordinating and facilitating each of the activities outlined in this strategy  Establish and implement an explicit organisation wide stakeholder engagement plan for the 2014-15 period, aligning with strategic priorities and key reporting areas.  Number and type of education/health literacy resources disseminated to community and stakeholders e.g. chronic disease management, immunisation schedule, dementia management, lifestyle risk factor management  Number and type of episodes of support provided to community and stakeholders by ESML e.g. community forums, CPD events, one-to-one practice visits, community events  Number completed patient experience questionnaires Health Literacy  Health care professionals provided health literacy resources or information regarding where to access resources  ESML community provided with health literacy resources or information regarding where to access resources  Increased understanding of barriers, limitations and enablers to primary health care service provision in the region Consumer and provider satisfaction with ESML o Strength of relationship with ESML o Opportunities for enhancement o Number and type of engagement activities conducted o Stakeholder evaluation outcomes regarding satisfaction and experience with service o Number and type of engagement activities conducted o Number and type of stakeholder groups/professions participating in engagement activities o Level of community and stakeholder satisfaction with ESML and engagement activities

[7] ACTIVITY NAME IDENTIFIED NEED

Alcohol and prescription medication management  

SO 1, 2

Reduce the inappropriate use of alcohol and improve access through revised pathways to treatment Reduce inappropriate use of prescription medications

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KRA 3

FP 1,2,5

Eastern Sydney Medicare Local 2014-15 Annual Plan

STRATEGY DURATION RESOURCING Description

 

Provide clear referral pathways to improve the care coordination for primary care providers Reduce the inappropriate use of alcohol and prescription medications and provide clear referral pathways to improve the care coordination for primary care providers 12 months (ongoing) $250,000 Alcohol Work together with South Eastern Sydney Local Hospital District and St Vincent’s Hospital Drug & Alcohol services to develop the specifications and evaluate the potential for implementing:  Outreach services in targeted regions to support management of alcohol issues, and offer patients and local services education about alcohol management options  Develop options with our partners to assist GPs to identify, treat, and refer patients with alcohol problems  Consumer and provider literacy resources to support drug and alcohol services developments disseminated via PSOs Reducing inappropriate prescriptions Develop and implement quality improvement activities focusing on GP prescribing behaviours, medication management and poly-pharmacy. Proposed activities will include; o Promote, educate and train GP use of Home Medicine Reviews and ePrescription o Education and training regarding use of clinical management guidelines supporting GP prescribing habits specifically for benzodiazepines and opioids o Support implementation of eReferral, eTransfer, eDischarge and ePrescriptions for patients accessing local hospitals specifically residents of aged care facilities  Aged care medication management program in community and RACFs  Continue to support implementation of eMedication Management projects with local hospitals and residential aged care facilities such as eDischarge, ePrescriptions and eTransfers  After Hours strategies to review medications in patients likely to require after hours care Governance Maintain governance structures to support implementation of the abovementioned activities through the following advisory/steering groups;  Mental Health  Chronic disease  Aged Care  eHealth  After Hours

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Eastern Sydney Medicare Local 2014-15 Annual Plan Type of activity

Region

This activity will broadly target the whole ESML region, with a specific focus on the Botany Bay region for activities such as outreach service provision Primary care providers related to the distribution and/or management of medications including but not limited to; GPs, Practice Nurses, Community Pharmacies, local hospitals, residential aged care facilitities, carer services, mental health services and social and welfare service providers It is anticipated that ESML will be responsible for coordinating and facilitating each of the activities outlined in this strategy  Establish partnership with South Eastern Sydney Local Hospital District and St Vincents Drug and Alcohol Services with formal terms of reference  Implement joint activities to address alcohol and medication management  Implement quality improvement activities to reduce prescriptions for benzodizapines and opiaod medications  Implement quality improvement activities to address issues associated with poly-pharmacy and address descrepencies in hospital (discharge)-to-community prescriptions  Implement quality improvement activities within aged care facilitities to prevent falls, improve medicaition management associated with transfer in/out of hospital  Establish an integrated models(s) of support for alcohol and medication management in the region with South Eastern Sydney Local Hospital District, St Vincent’s Hospital and Sydney Children’s Hospital Network  Improved identification of alcohol related issues in patients  Improved responsiveness to alcohol related problems by GPs and facilitated onward referrals (through education of GPs and improved pathways to increase service access including the option for local community service delivery in areas of identified high need)  Number and type of quality improvement interventions implemented (descriptive)  Self-reported prescribing behaviours (before and after intervention)  Increase in the number of Home Medicines Reviews conducted across the region  Number of ePrescriptions, eTransfers, eReferrals and eDischarge summaries uploaded between local hospitals and RACFs

Sector

Service Provider Performance information

Expected outcome

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Eastern Sydney Medicare Local 2014-15 Annual Plan [8] ACTIVITY NAME

SO 1, 2,

Youth service support

KRA 4

FP 1,5

IDENTIFIED NEED

Improve the availability of youth related primary care services in relation to; mental health, sexual health and drug and alcohol

STRATEGY

Collaborate with local primary and secondary care services to coordinate the delivery of care for youth with drug and alcohol issues. The strategy will address the whole region, with a specific focus on supporting access for youth in the Botany Bay Local Government Area Targeted regions  Work collaboratively with the Drug and Alcohol Services from South Eastern Sydney Local Hospital District, St Vincent’s and the newly established mental health unit from Sydney Children’s Hospital (Randwick) to establish drug and alcohol outreach project(s). The projects will target marginalized groups across the region, specifically; youth, people with a mental health condition, CALD groups, Aboriginal and Torres Strait Island communities and residents of the Botany Bay Local Government Area.

Description



Approaches to be investigated include; aligning activities with local schools, community groups, and other agencies that work with young people

Drug & Alcohol  Ensure drug and alcohol options are included within the development of the Bondi Junction located Headspace; ideally this will be linked to the Botany Bay project but extended to other communities, for example, Eastlakes’ area to support accessibility for economically disadvantaged communities for the region  Ensure that the Eastern Suburbs Partners in Recovery project improves access for young people to relevant services – this will be achieved through developing referral pathways with the SESLHD child and youth mental health service in Bondi Junction.  Develop pathways for young people to access the ATAPS service; this is will include the development of onsite ATAPS services at the new Headspace in Bondi Junction and exploration of an outreach model for youth ATAPS in vulnerable communities, including access from schools. Sexual Transmitted diseases  Work collaboratively with the South Eastern Sydney Local Hospital District HARP Unit, and peak bodies such as ASHM, ACON, NSW Sexual Health Unit (STIPU), to support the prevention and treatment of sexually transmitted infections across the region  Continue to support the implementation of existing activities implemented via the abovementioned stakeholders such as provider education, consumer education and dissemination of resource

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Eastern Sydney Medicare Local 2014-15 Annual Plan 

Type of activity

Region Sector

Service Provider Performance information

Expected outcome

Ensure STI options are included within the development of the Bondi Junction Headspace service ; ideally this will be linked to the Botany Bay project but extended to other communities, for example, Eastlakes’ area to support accessibility for economically disadvantaged communities for the region  Ensure that the Eastern Suburbs Partners in Recovery project and Headspace Centre improves access for young people to relevant services – this will be achieved through developing referral pathways with the stakeholders outlined above Strategy will include the following types of activities;  Engagement with key stakeholders  Aligning the strategy with existing (ESML) initiatives  Establishing formal partnerships with key stakeholders (LHN, LHD and relevant providers)  Planning and evaluation This activity will broadly target the whole ESML region, with a specific focus on the Botany Bay region for activities such as outreach service provision  All primary health care providers servicing the region with a relevance to the prevention drug and alcohol treatment, youth health, mental health and related conditions  Relevant government/non-government, social, welfare and charitable service providers such as; culturual groups, Aboriginal and Torres Strait Island community groups, local councils, homeless services, drug and alcohol, housing and community services, police and corrective services. It is anticipated that ESML will be responsible for coordinating and facilitating each of the activities outlined in this strategy  Establish partnership with South Eastern Sydney Local Hospital District (SESLHD) and St Vincent’s (SVH) Drug and Alcohol Services with formal terms of reference  Identify collaborative partnerships with representatives from the Sydney Children’s Hospital (Randwick) Mental Health Service  Implement joint activities to support issues associated with youth drug and alcohol consumption  Establish memorandum of understanding with Headspace (SESLHD) for service delivery of ATAPS and Partners in Recovery (PIR) to youth across the region  Develop referral/care pathways for youth incorporating ATAPS, Headspace, PIR, SESLHD, SVH, Sydney Children’s Hospital and SESLHD School Link services  Develop youth pathway for PIR from relevant referrers e.g. child and youth SESLHD services and NGOs  Increased access to youth drug and alcohol services  Strengthened partnerships with local youth, drug and alcohol service providers  Clearly defined referral/care pathways for treatment of youth drug, alcohol and sexually transmitted infections  Increased capacity in the local health care system to manage youth drug, alcohol and STIs as a result of coordinated services between ESML, SESLHD, SVH and SCH

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Eastern Sydney Medicare Local 2014-15 Annual Plan

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Eastern Sydney Medicare Local 2014-15 Annual Plan

[9] ACTIVITY NAME

After hours services

IDENTIFIED NEED

Provide clear referral pathways to improve the care coordination for primary care providers

STRATEGY

Type of activity

Maintain support for existing after hours services. Identify and obtain commitment of a further 15% - 20% of GPs to refer to the MDS  ESML will continue to provide an incentive payment to GPs to expand their hours of operation or contract the services of a Medical Deputising Service. Promotional collateral will be developed to raise consumer awareness of Out of Hours Health Services. Support for expanded after hours health services will be provided and delivered to high need areas.  Improving capacity and access to after hours in Eastern Sydney.

Region

This activity will broadly target the whole ESML region

Sector



Service Provider

ESML will subcontract these services through the existing providers

Performance information

Increased use of Health Direct and primary care health services during the after hours period. Reduced attendances of Category 4/5 patients at local Hospital emergency wards.  Increased capacity of Out of Hours Health Services in Eastern Sydney.

Description

Expected outcome

SO 1, 2,

KRA 4

FP 1,5

GP, Consumers, Residential Aged Care Facilities, Allied health

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Eastern Sydney Medicare Local 2014-15 Annual Plan

[10] ACTIVITY NAME

Maintain strong quality, governance and support systems.

IDENTIFIED NEED

Continuing the development of a strong governance and program support model for ESML

STRATEGY

Continue to develop and ensure effective governance structures and sound program delivery support are in place including Risk Management and development of quality management systems Maintain an effective Quality Management system Establish People and Culture program Maintain Policies and Procedures to meet relevant Standards, Compliance and Risk Management requirements

Description

Type of activity

SO 1,5

KRA 1-5

FP 1,5, 6

Region

These are mandated organisational development activities intended to maintain and improve governance and program delivery capacity across ESML Impacts whole region

Sector

Every sector will benefit

Service Provision

ESML

Performance information

QM system established and operating successfully.

Expected outcome

Improved use of ESML resources; greater role clarity; improved knowledge management, corporate governance and clinical governance; enhanced people and culture practices

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Eastern Sydney Medicare Local 2014-15 Annual Plan

Risk management plan Risk

Likelihood of risk (Low, Unlikely, Possible, Likely, Almost Certain)

Consequence of risk (Provide a brief example of the consequence)

Risk Rating (Low, Medium, High, Extreme)

Mitigation Strategy *

Likely

Disrupted processes; wasted effort in having to repeat planning processes; inability to recruit to replace lost staff

High

Keep staff and stakeholders informed of changes. Implement processes which are responsive to changes as they occur.

ESML is slow to respond to changes / new opportunities

Possible

Under-delivery of programs

High

A deal of time is required to translate the Strategic Plan into appropriate operational and individual work plans. Continuing relationship

Likely

Inappropriate allocation of resources or confused priorities

Medium

Possible

Withdrawal / delayed

High

Improved operating structures and a new approach to BAU has enabled improved responses and progress. Improved operating structures and a new approach to BAU has enabled improved responses and progress. Maintain a positive and

Strategic / Political 2014 Budget changes have created / may lead to:  Difficulties in planning and implementing those things which have changed but have yet to be confirmed / detailed / documented.  Staff resignations in face of uncertain futures  Perceptions of a “failed” organisation  Organisational decay

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Eastern Sydney Medicare Local 2014-15 Annual Plan

Risk

Likelihood of risk (Low, Unlikely, Possible, Likely, Almost Certain)

with DoHA not as positive as it should be

Finance / Internal Controls Inadequate emphasis is placed on need for integrity and ethical values

Consequence of risk (Provide a brief example of the consequence)

Risk Rating (Low, Medium, High, Extreme)

funding. Lost time dealing with queries / breaches etc. Reputation damage. Lost opportunities to tender for / be involved in other programs

constructive relationship with DoH. Ensure all deliverables are met.

Possible

Inadequate regard for funding guidelines and internal controls may lead to poor expenditure patterns

Medium

Incompetent employees may be hired or retained

Possible

Under-performance, conflict

Medium

Ineffective management oversight provided by those charged with

Possible

Poor governance; breaches of funding agreement; insolvent trading.

High

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Mitigation Strategy *

Management demonstrates through words and deeds a commitment to high ethical standards A code of conduct and similar set out ESMLâ&#x20AC;&#x2122;s expectations of employee behaviour Employees understand what behaviours are unacceptable Appropriate recruitment processes identify suitability of candidates ESML supports training to broaden the skills of employees Job descriptions exist and are effective Adequate staffing levels are maintained Board comprises nonexecutive directors only. Significant issues are

Eastern Sydney Medicare Local 2014-15 Annual Plan

Risk

Likelihood of risk (Low, Unlikely, Possible, Likely, Almost Certain)

Consequence of risk (Provide a brief example of the consequence)

Risk Rating (Low, Medium, High, Extreme)

governance

Management has a poor attitude to internal controls and management of business risks

Possible

Inappropriate spending; decisions which do not adequately take account of risks

High

Ineffective / inappropriate organisational structure

Possible

Poor service delivery; slow response to change

Medium

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Mitigation Strategy *

reported and reports are provided to Board in a timely manner Board meets monthly â&#x20AC;&#x201C; minutes are circulated. Audit committee has a charter and defined responsibilities in support of Board governance. There is discussion around the existence and effectiveness of internal controls. Board and management demonstrate positive attitudes through: Adoption of delegations manual and appropriate internal control procedures Choices of accounting policies Support of accounting personnel in application of policies and procedures Establishing physical access controls on premises, computers, databases Analysis and regular review of business risks Recent structural review created new management

Eastern Sydney Medicare Local 2014-15 Annual Plan

Risk

Likelihood of risk (Low, Unlikely, Possible, Likely, Almost Certain)

Consequence of risk (Provide a brief example of the consequence)

Risk Rating (Low, Medium, High, Extreme)

Mitigation Strategy *

structure and project management system. This has created capacity within the organisation. Fraud Prevention Management does not adequately assess the risk of fraud

Compliance Failure to meet lodgement / reporting obligations, both statutory and Agreement-driven

Possible

Fraudulent expense claims or EFT transfers

Medium

ESML culture minimises employee sense of threat. Management behaviours send a message that it will respond to and deal with suspected fraud. Fraud risk is identified and assessed in planning processes. Delegations policy adopted and applied consistently. Close control over bank account access. Board regularly assesses fraud risks and controls. Management has a policy of informing the auditor on a timely basis about actual, suspected or alleged fraud.

Possible

Late lodgement penalties, etc DoH can amend/suspend funding for delayed

High

Deliverables report maps and identifies obligations and time-based commitments to funders

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Eastern Sydney Medicare Local 2014-15 Annual Plan

Risk

Likelihood of risk (Low, Unlikely, Possible, Likely, Almost Certain)

Consequence of risk (Provide a brief example of the consequence)

Risk Rating (Low, Medium, High, Extreme)

submissions

Motor Vehicles Speeding and other offences unable to be identified back to offending driver Drivers have recurrent offences or accidents

Population Health Lack of comprehensive understanding of the needs and health priorities for the ESML region

Mitigation Strategy *

and others – reviewed monthly by Board – riskbased report which identifies and “at risk” activities CFO and Finance Officer monitor key statutory deadlines to ensure compliance CFO and Finance Officer monitor Funding deliverables, invoicing and receipts

Unlikely

ESML bears costs

Medium

Vehicle use log and location of offence to identify driver

Possible

There is an underlying costs to ESML from vehicle damage

Medium

Records maintained of driver offences / accidents history. Repeat offenders identified for relevant corrective action

Possible

Development of plans and activities that do not support the needs of the community Limited reduction in disease burden or improvements

High

Formal partnership with SESLHD, SCH and SVH to collate relevant data for needs assessment Establishment of a formal governance structure to

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Eastern Sydney Medicare Local 2014-15 Annual Plan

Risk

Likelihood of risk (Low, Unlikely, Possible, Likely, Almost Certain)

Consequence of risk (Provide a brief example of the consequence)

Risk Rating (Low, Medium, High, Extreme)

to patient journey Limited engagement with key stakeholders Poor understanding of the role of ESML in primary health care delivery

Continued low childhood immunisation coverage in the region

Likely

Increased risk of communicable diseases within the community Increase political spotlight regarding low immunisation coverage Limited population compliance with national legislation regarding immunisation coverage

Medium

Limited feedback regarding patient experience with local primary health care services.

LIkely

Inadequate understanding of patient barriers and enablers to local health services and satisfaction with level of service provide Planning does not

Medium

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Mitigation Strategy *

provide advice regarding design and implementation of the needs assessment Comprehensive plan for project building on work previously completed through the 2014 needs assessment Allocation of sufficient resources to ensure comprehensive completion of the project Development and implementation of intensive follow-up process for late vaccinations Capacity building activities within local general practices to support sustained follow up of late vaccinations Community promotional activities to enhance awareness of benefits and points of access for immunisation Identification of robust methods for measuring and analysing patient experience across a representative sample of consumers for the region

Eastern Sydney Medicare Local 2014-15 Annual Plan

Risk

Likelihood of risk (Low, Unlikely, Possible, Likely, Almost Certain)

Fragmented referral pathways for patients with established or diagnosed chronic disease

Likely

Limited awareness of local services to address lifestyle risk factor management and chronic diseases

Likely

Consequence of risk (Provide a brief example of the consequence) address the needs of consumers Poor understanding of the patient/consumer needs for primary health care delivery in the region Limited identification of relevant service providers for disease states/conditions. Limited coordination and integration primary health care services in the region. Limited ability to support ESML strategic objectives to integrate and coordinate primary health care services in the region Planning does not address community needs. ESML not able to improve specific patient journeys.

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Risk Rating (Low, Medium, High, Extreme)

Mitigation Strategy *

Collate outcomes from analysis and use when developing plans to respond to needs and gaps

Medium

High

Comprehensive service mapping for relevant chronic disease Identification of access facilitators such as MBS items, referral resources Coordination of processes for managing chronic diseases Collation an dissemination of patient and provider support resource Comprehensive service mapping for relevant service providers including access information and resources Promotion of relevant service providers and access resources such as referral resources Implementation of population health approaches to promotion of strategies to access

Eastern Sydney Medicare Local 2014-15 Annual Plan

Risk

Detailed understanding of preventative health programs may not be possible due to the lack of data available.

Communications Incorrect information released

Likelihood of risk (Low, Unlikely, Possible, Likely, Almost Certain)

Consequence of risk (Provide a brief example of the consequence)

Risk Rating (Low, Medium, High, Extreme)

Likely

Future focus of preventative health may have to be modified later in the year or in future years to better suit the needs of the local population Mapping of gaps, opportunities and planned efficiencies may not be an accurate reflection of the current needs and future demand

Medium

Likely

Disruption to practitioners, events, activities, brand

High

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Mitigation Strategy *

health service providers such as MBS items ESML will engage national, state based and local offices of member organisations of primary care providers to encourage participation in the preventative health agenda. ESML will engage with appropriate organisations to obtain data from previous Divisions of General Practice and Local Health Districts to inform this process ESML will work closely with all relevant stakeholders in the planning, development, implementation and evaluation of all preventative health programs/services within the ML area to ensure â&#x20AC;&#x153;buy-inâ&#x20AC;? and reduce the risk of lack of engagement. Approval / sign-off processes

Eastern Sydney Medicare Local 2014-15 Annual Plan

Risk

Likelihood of risk (Low, Unlikely, Possible, Likely, Almost Certain)

Non-adherence to brand guidelines

Likely

Missed deadlines editorial, reporting, production Relationship issues - media suppliers; stakeholders Decision-making impacted by lack of or use of poor data

Likely

Possible Possible

Consequence of risk (Provide a brief example of the consequence) damage Brand confusion, inappropriate style/presentations Missed opportunities; nontimely delivery Disruption to planning / activities Poor decisions or choices

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Risk Rating (Low, Medium, High, Extreme)

Mitigation Strategy *

High

Use of templates insistence on same

Medium

Establish approval and planning processes; priority-setting Focus on key elements of relationships Ensure quality data employed or best estimates

Medium Medium