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Connecting Care Workshop Day 2

Connecting Care Workshop Day 2. August 2009. Where have we come from?. COAG 2006 .....4 yr $500 million national program called the Australian Better Health Initiative (ABHI) to strengthen the health system’s focus on promoting good health and reducing the burden of chronic disease.

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Connecting Care Workshop Day 2

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  1. Connecting Care WorkshopDay 2 August 2009

  2. Where have we come from? COAG 2006.....4 yr $500 million national program called the Australian Better Health Initiative (ABHI) to strengthen the health system’s focus on promoting good health and reducing the burden of chronic disease. ABHI was composed of 5 priority areas: • Promoting healthy lifestyles • Supporting early detection of risk factors and chronic disease • Supporting lifestyle and risk factor modification • Encouraging active patient self management of chronic conditions • Improving integration and coordination of care

  3. National Overview – key activities.... • National Health and Hospitals Reform Commission final report • National Preventative Health Taskforce • National Primary Health Care Strategy • COAG activities • APCC • National CDPM Network • National PCIP Network • GPLO • ABHI PCIP State overview

  4. State Overview –key activities • Queensland Health; Enterprise Discharge Summary (EDS) Project, Statewide Clinical Networks • Connecting Healthcare in Communities (CHIC) Initiative • eHealth • Division Profiles • October Forum

  5. References • A healthier future for all Australians - Final Report June 2009. Commonwealth of Australia, 2009. http://www.health.gov.au/internet/main/publishing.nsf/Content/nhhrc-report (accessed August 2009). • Australian Better Health Initiative (ABHI) fact sheet. Commonwealth of Australia, 2007. http://www.measureup.gov.au/internet/abhi/publishing.nsf/Content/factsheet-abhi (accessed August 2009). • Bennett C. (Chair) Presentation: A Healthier Future for all Australians: Final Report June 2009. National Health and Hospitals Reform Commission. 2009. • Cotton L. (A/g Director, Integration and Self-Management, Chronic Disease Branch, Primary and Ambulatory Care Division) Presentation: Australian Better Healthcare Initiative Primary Care Incentive Program. Australian Government Department of Health and Ageing, 2009. • Djakic E, Butt D. National Health and Hospitals Reform Commission, A Healthier Future for All Australians – Final Report June 2009, Summary of key findings relevant to general practice and divisions network. Australian General Practice Network. ACT, 2009. • General Practice Queensland . GPQ Update 75. Brisbane, 2009. • General Practice Queensland. Workplan. Brisbane, 2008. • Primary Health Strategy. Australian Government Department of Health and Ageing, 2008. http://www.health.gov.au/primaryhealthstrategy (accessed August 2009). • With sincere thanks to Sarah Bradfield GPNSW whose workshop and documentation have informed this presentation. Thanks also to the GPQ eHealth Team for their input.

  6. Novel ideas…. Pathway projects from • Simon - Shared electronic health summary/RCH referral tools and pathways • Vicki - Type 2 Diabetes Pathway • Rhonda - TCA Management System • Jon - Local Clinical & Service Delivery Pathways • Robina - GP Shared Clinical Pathways Program • Lisa – Chronic Complex Care

  7. Morning Tea

  8. More on pathways…definitions

  9. World Health Organisation definition WHO Centre for Health Development. Ageing and Health Technical Report Volume 5, A Glossary Of Terms For Community Health Care And Services For Older Persons. World Health Organisation: Japan, 2004. • Care pathway An agreed and explicit route an individual takes through health and social care services. Agreements between the various providers involved will typically cover the type of care and treatment, which professional will be involved and their level of skills, and where treatment or care will take place (p12)

  10. National Library of Medicine definition National Library of Medicine - Medical Subject Headings.National Library of Medicine, 2009. http://www.nlm.nih.gov/cgi/mesh/2009/MB_cgi?mode=&index=17820&view=expanded (accessed August 2009). • In the MeSH section of the NLM website the Scope Note regarding Critical pathways is - Schedules of medical and nursing procedures, including diagnostic tests, medications, and consultations designed to effect an efficient, coordinated program of treatment.

  11. AGDHA definition ABHI: PCIP 2009/10 reporting requirements Technical Details and Instructions. Australian Government Department of Health and Ageing. http://www.phcris.org.au/divisions/reporting/documents/ABHI_PCIP_Technical_Details_09-10_FINAL.pdf (accessed August 2009). • Integrated Shared Care Pathways are about agreedcommunication and coordination processes (eg. referral and feedback, care planning, case conferencing); and such pathways may involve private and/or public providers. They can also be known as coordinated carepathways, care maps, or anticipated recovery pathway. ISCPs aretask orientated care plans which detail essential steps in thecare of patients with a specific clinical problem and describethe patient's expected clinical course. They offer a structuredmeans of developing and implementing local protocols of carebased on evidence based clinical guidelines. (p1)

  12. Queensland Health Clinical Practice Improvement Centre definition Clinical Pathways. Queensland Government Clinical Practice Improvement Centre, 2009. http://www.health.qld.gov.au/cpic/service_improve/clinical_pathways.asp (accessed August 2009). • Clinical pathway A document outlining a standardised, evidence-based, multi disciplinary management plan, which identifies an appropriate sequence of clinical interventions, timeframes, milestones and expected outcomes for an homogeneous patient group.

  13. The European Pathway Association definition The European Pathway Association. http://www.e-p-a.org/index2.html (accessed August 2009). Clinical/care pathway A methodology for the mutual decision making and organization of care for a well-defined group of patients during a well-defined period. Defining characteristics include an explicit statement of the goals and key elements of care based on evidence, best practice and patient expectations; the facilitation of the communication, coordination of roles and sequencing of the activities of the multidisciplinary care team, patients and their relatives; the documentation, monitoring and evaluation of variances and outcomes; and the identification of the appropriate resources. The aim of a care pathway is to enhance the quality of care by improving patient outcomes, promoting patient safety, increasing patient satisfaction, and optimizing the use of resources.’ (Homepage)

  14. References • ABHI: PCIP 2009/10 reporting requirements Technical Details and Instructions. Australian Government Department of Health and Ageing. http://www.phcris.org.au/divisions/reporting/documents/ABHI_PCIP_Technical_Details_09-10_FINAL.pdf (accessed August 2009). • De Bleser L, Depreitere R, De Waele K, Vanhaecht K, VlayenJm & Sermeus W. Defining Pathways. Journal of Nursing Management. 2006: 14, 553-563. • National Library of Medicine - Medical Subject Headings.National Library of Medicine, 2009. http://www.nlm.nih.gov/cgi/mesh/2009/MB_cgi?mode=&index=17820&view=expanded (accessed August 2009). • Clinical Pathways. Queensland Government Clinical Practice Improvement Centre, 2009. http://www.health.qld.gov.au/cpic/service_improve/clinical_pathways.asp (accessed August 2009). • The European Pathway Association. http://www.e-p-a.org/index2.html (accessed August 2009). • WHO Centre for Health Development. Ageing and Health Technical Report Volume 5, A Glossary Of Terms For Community Health Care And Services For Older Persons, World Health Organisation: Japan, 2004.

  15. The Map • Introduction • Features • Promotion • Submissions • Trial www.gpqld.com.au/map/

  16. Lunch

  17. Reporting

  18. How we report

  19. ABHI - PCIP 1 Results against the ABHI – PCIP local performance indicators as outlined in your annual/work plan • Progress with planned activities/approaches • Are your planned activities/approaches likely to be achieved for this focus area? • Successes/challenges in this focus area Upload plan with progress

  20. ABHI - PCIP 2 The number and proportion of general practices using integrated shared care pathways or business rules to support chronic disease prevention and management [Jul 08-Jun 09] There will be a table asking you to provide details of your data collection process, qualitative data including evidence of outcomes and an explanation of results Collection; surveys, practice visit data, by phone, by interview Explanation; 200 word limit, look at any limitations to what you’ve been able to measure

  21. ABHI - PCIP 3 Divisional involvement in the work being progressed locally through state government funded programs (eg the HealthOne NSW initiative, clinical redesign etc) to support chronic disease prevention and management [Jul 08-Jun 09] You will be asked for qualitative data including evidence of the outcomes achieved. Information reported can highlight challenges, solutions or innovations identified in the work being progressed Qld state government funded programs could involve for example CHIC, Chronic Disease funding, Place-Based Initiatives or local QH projects such as Aged Referrals

  22. ABHI - PCIP 4 The extent to which general practices use a communications application, or an electronic system between primary care providers and hospitals where relevant, that supports the timely and appropriate exchange of patient information (eg clinical software tools, secure messaging.) [Jul 08-Jun 09] You will be asked for qualitative data including evidence of the outcomes achieved Could include secure messaging (referrals, discharge summaries, electronic health records etc) and associated templates. Could explore background to enhancing uptake eg workshops, collaboratives etc

  23. ABHI - PCIP 5 The number and proportion of general practitioners claiming MBS GP Management Plans, Team Care Arrangements and Multidisciplinary Care Plans. [Jul 08-Jun 09] There will be a table for you to explain your results. 200 word limit. Enter data provided by AGDHA. Consider the reasons for any changes in the figures compared with previous reports • Staffing issues • Technical issues • Whether ABHI PCIP or other division programs have influenced these

  24. ABHI - PCIP 6 The number and proportion of general practitioners claiming case conferencing items. [Jul 08-Jun 09] There will be a table for you to explain your results. 200 word limit. Enter data provided by AGDHA. Consider the reasons for any changes in the figures compared with previous reports • Staffing issues • Technical issues • Whether ABHI PCIP or other division programs have influenced these

  25. ABHI - PCIP 7 The number and proportion of general practitioners claiming Medication Management Review items. [Jul 08-Jun 09] There will be a table for you to explain your results. 200 word limit. Enter data provided by AGDHA. Consider the reasons for any changes in the figures compared with previous reports • Staffing issues • Technical issues • Whether ABHI PCIP or other division programs have influenced these eg QUM

  26. ABHI - PCIP 8 The objective of PCIP is to encourage more integrated patient centred care by supporting general practice to: • Engage with the work of local Primary Care Partnership Councils and other state-funded primary care initiatives that seek to improve service co-ordination and integrated chronic disease prevention and management (eg CHIC) • Communicate and link better with other primary care providers (eg secure messaging, IPL, newsletters) • Make better use of existing primary and community care services including Commonwealth, State and non-government organisation funded services with a focus on patients with chronic disease (eg informing practices of local services) • Utilise tools/strategies that will assist in better managing patients with chronic disease (e.g. disease registers, referral, recall & reminder systems, care planning) • Contribute to work around developing local chronic disease care pathways (generic or specific) or other priority activities with a chronic disease management focus. You will be asked about the extent to which these objectives have been achieved. 300 word limit for all.

  27. ABHI - PCIP 9 The Participant has been funded to support and encourage general practice to incorporate integrated primary health care into their core business and to work more collaboratively with other primary care providers in the prevention and management of chronic disease. You will be asked about the extent to which this objective has been achieved. 300 word limit. Give examples. May include number of GPs engaged in this change process and whether the influence has been broader than those directly involved in the change process Note any linkages or networks supporting sustainability eg APCC, GPLO (if relevant)

  28. ABHI - PCIP 10 The Participant has been funded to adopt a range of strategies that include (but not exclusively): • Working collaboratively with the ABHI Primary Care Incentive Program Statewide Coordinator, ensuring that where relevant, activities are implemented consistently across the State (or Territory); GPQ workshops/forums, teleconferences, phone calls and emails • Promoting to general practice the importance and benefits of integrated primary care service delivery in the prevention and management of chronic disease; APCC • Building a knowledge-base on the factors that act as barriers against, or act to increase, the engagement of general practice in integrated primary care service delivery to prevent and manage chronic disease; how you may have shared your solutions to barriers with others or discussed their solutions eg other programs in your division • Promoting and identifying examples of best practice and facilitate transfer across general practices; Clinical Practice Improvement Centre/Statewide Clinical Networks • Providing resources and where relevant, training (or organising training) to general practice staff in the use of information tools and services, in the context of integrated primary care services delivery; practice visits, workshops, postings on your website • Sharing with the Divisions of General Practice Network best practice knowledge and resources around integrated primary care service delivery models relevant to the prevention and management of chronic disease. In this respect, any materials produced in the course of this Project (e.g. communication strategy, business rules etc) by the Participant are to be shared with the Divisions Network via the AGPN clearinghouse) workshop sharing, linkages with other divisions, articles for the state and national newsletters, contributions to the ‘Map’ You will be asked about the extent to which these objectives have been achieved. 300 word limit for all.

  29. References Sarah Bradfield. GPNSW Cheat Sheet. 2009 Merrian Oliver-Weymouth. GPV Primary Care Update.

  30. www.chinatownconnection.com/.../iguazafalls.jpg

  31. Afternoon Tea

  32. Sustainability What is it? ‘When new ways of working and improved outcomes become the norm (p12) How can we improve it? • Plan for it • Avoid change being isolated and link with other initiatives • Look at bigger picture effects • Win hearts and minds • Involve the team • Train staff • Look at systems - structures, processes and patterns • Check for value consistency • Encourage improvements to the change • Celebrate successes How to demonstrate you’re achieving it? NHS Modernisation Agency. Improvement Leaders’ Guide to Sustainability and spread. Crown: Ipswich, 2002.

  33. Workshop Evaluation

  34. Thank you

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