Partnerships and collaboration for a strong primary health care system

Transcription

1 Jan Child, Chief Operating Officer Peninsula Health 25 th September 2014 Partnerships and collaboration for a strong primary health care system

2 Frankston and Mornington Peninsula - FMP 2

3 A beautiful part of the world with some Wicked Problems Hot spots and high risk factors: High Smoking rates; Overweight; Alcohol and other drug use; Poor nutrition; Stress; Poor mental health: High levels of vulnerability among children; High child protection rates, Scant public transport; Variable access to services by those who most need them; Early school leaving rates; Teenage pregnancy; Youth disengagement and social exclusion; High rates Dementia, Violence against women and children; Community violence; Low birth weight babies; Ageing in 3 poverty.

4 36% of FMP has SEIFA rankings in 1st decile And on this slide add some dot points I am about to send you 4

5 Peninsula Model Founding Partners

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7 What is The Peninsula Model for Primary Health Planning? Based on agreed Population Health Priorities Collaboration between health planners and providers towards agreed catchment health priorities Targeted responses to identified local health priorities e.g. mental health and aged care Unique in its breadth of partnership (includes Local Government, 4 Government Departments, PCP, etc) Dedicated and sustainable function to facilitate service development and re-design (FMPML + FMPPCP) Leverages the substantial pool of local provider resources to greater effect. 7

8 Shared Goals Consumer (C) Shared Goals Address the service gaps for local consumers Outcomes Accessible, equitable services that meet local consumer health needs Service Delivery (SD) Health Promotion (HP) Service System (SS) Provide consumer-centred, coordinated and integrated services Impact the long term health of the local community through targeted and impactful health promotion initiatives Improve capacity to deliver evidence based care Improved consumer health journeys Improved long term health of the community Resources and capabilities better aligned to meet local needs at a consistent high standard

9 Governance Structure Strategy PC&PH Committee Authorising environment Partner engagement Board/CEO level Coordination FMPML FMP PCP PMEG Population health & health priorities Project resources Data analysis Tools / Methodology Evaluation Reimburse clinician / consumer participation Oversight / Direction Partner consensus Agree priorities Drive and structure the work Resource the work Partnership development Support systems (e.g. e-care pathways, secure messaging) Communications / Events Alliances Practitioner expertise Sector knowledge Develop joined up solutions Delivery Providers / Agencies Partner to deliver solutions

10 8 Agreed Population Health Alliances: Alliance Key Priorities Aboriginal Health Alliance Cultural strengthening Coordinated prevention initiatives Coordinated service delivery Ageing Well Alliance Improve dementia care Increase advanced care planning Improve social connectedness Chronic Disease Management Alliance Prevention and Better Health Alliance Chronic pain Chronic heart failure Diabetes Smoking cessation Chronic disease prevention Family violence prevention Alcohol and Other Drugs Alliance Improve early intervention Improve access to pharmacotherapy Improve system to address dual diagnosis Mental Health Alliance Address homelessness Coordinated care pathways Develop a peer workforce Address youth mental health issues (including suicide) Children s Health Alliance Pathways to early intervention for children and vulnerable families Advocacy for more services Ehealth Alliance Electonic referral PCEHR

11 Overarching Achievement for Alliances 8 Alliances meeting regularly with agreed work plans 5 Alliances with agreed evaluation plans (and baseline data collected to support evaluation of outcomes) Up to 50 projects across Alliances, with 28 outputs delivered and outcomes in some Alliances measured (from baseline) Over 40 agencies, 35 private primary care providers (GPs), 4 government departments and many consumers involved (235 different individuals involved) - a truly multi-sectoral approach Clinical Governance and implementation of one pathway tool Map of Medicine - pathways being developed by 7 of the 8 Alliances Peninsula Model currently being evaluated by the Lime Consulting Group

12 Ageing Well Alliance Achievements: Dementia strategy (endorsed by all key organisations providing aged care) - Increased community referrals to dementia services Dementia care pathway (with a focus on early identification and improved support to carers) More day respite places opened up by 2 RACFs Development of a caring passport - Peninsula Health / Brotherhood of St Laurence / Others sharing management strategies Delivery of dementia training to over 80 general practice clinicians - now familiar with pathways and local services focus on practice nurses Development of 1 agreed ACP ( from over 30) including agreed user guides for consumers and providers ACP embedded into ACAS and HACC assessments ACP systems developed with select RACFS with a commitment to ensure every resident has an ACP in place Greater numbers of pots presenting to ED with ACP s

13 Children's Health Alliance Achievements: Care Pathways children with development delay 0-5 / 6-12yrs / asthma management Common Resources for parents (designed with a literacy lens) One resource being used across the catchment by all services (being distributed by GP s, MCH, PH & ECIS) Service navigation resources - NHSD populated with children s service information and made available through a widget on FMPML website Collaborative care model between GPs and MCH established - education events; local orientation meetings (2 conducted, 9 more planned); resources for GPs explaining MCH ages and stages (developed and being distributed); protocols for MCH communication being developed Submissions advocating for services to government Pathways to health assessments for children in out of home care

14 Mental Health Alliance Achievements: Care Pathways management of depression for adults / young people / dual diagnosis Rooming house project (to ensure residents with mental illness are connected with local services) - Protocols developed for rooming house operators; Pilot project conducted in Mornington Peninsula Shire to connect all residents with health and social services with excellent outcomes (report of findings currently being collated) Development and implementation of a peer workforce strategy across all mental health agencies (acute & community); Framework being developed; Baseline data being collected A coordinated prevention response to youth suicide - All relevant agencies developing shared protocols

15 Chronic Disease Management Alliance Achievements: Work plans finalised for all three priorities, with individual consultation conducted with each agency and significant buy in from private providers Care pathways for all priorities underway heart failure, chronic pain & diabetes Heart failure telehealth project Diabetes project with 5 general practices (baseline data collected, last month s achievement included an increase of 87 people screened for diabetes risk) GP clinical education and attachment program for chronic pain & pharmacotherapy to assist GPs do better medication management 15

16 Prevention & Better Health Alliance Achievements: Draft Family Violence Prevention strategy developed for the catchment and out for comment Smoking Cessation and Tobacco Control action plan drafted / organisational audit tool completed in 7/8 organisations which assisted in identifying issues and drafting action plan Participation in the Tobacco Benchmark Achievement Program Training needs assessment regarding primary prevention completed across a broad range of agencies (large response by local council) Collective Impact workshop conducted and approach to be used for a place based initiative

17 ehealth Alliance Achievements: Working in a coordinated way with other Alliances ereferral system for the whole catchment currently procured: a unique approach that will provide an enterprise licence for all providers in the catchment. Implementation to commence in October over 3 phases Phase 1 to include aged care, mental health, 10 GPs and their natural referral networks (GPs, allied health and specialists recruited and very committed to the process) Phase 2 to include the education sector (with education to make a financial contribution) 17

18 Aboriginal Health Alliance Achievements: Health promotion events being coordinated across the catchment Strategically planned and coordinated longer term health promotion programs Developing approaches to improve coordination of service delivery such as use and coordination of a shared care plan for with a family focus (rather than an individual focus) Working with gathering places to offer health promotion initiatives and support positive connections with the community.

19 Alcohol & Other Drugs Alliance Achievements: Recently established as part of the new AOD reforms The following priorities have been agreed and work plans being developed: Increase access to pharmacotherapy Improve the response to dual diagnosis Build an early intervention system Build an integrated, accessible and responsive AOD service system Capacity building for the primary care and community services sector underway 19

20 Key Success Factors Contained boundary Existing culture of partnership Change leaders with shared vision Championed by the LHN, Local Government and ML Driven and resourced by ML, and now PCP Robust Governance structures Population health and service integration expertise Primary care clinician and consumer involvement Focus on delivering outcomes.. Keeps people at the table. 20

21 Benefits to Health Service 1. Our clinicians have greater buy in to whole patient journey - eg Stop before the Op, 2. Improved relationships and collaboration between GP s and Physicians. Private and Public Allied Health, Specialists such as Diabetes Coordinators 3. Improved communication across the continuum less them and us 4. Reduced Admissions RACF, ACP, RHED 5. Better for our patients 21

22 The Peninsula Model