Primary Health Netwrks Greater Chice fr At Hme Palliative Care Central Queensland Wide Bay Sunshine Cast PHN Dcument cntrl 1
1. Planned activities funded under the Activity Primary Health Netwrks Greater Chice fr At Hme Palliative Care Funding Prpsed Activities Activity Title Descriptin f Activity Descriptin Greater Chice fr At Hme Palliative Care (GCfAHPC) Prject. Central Queensland, Wide Bay, Sunshine Cast PHN (the PHN) aims t effectively participate in the statewide strategy fr end f life care (EOLC) within ur regin t implement the Greater Chice fr At Hme Palliative Care thrugh a number f key strategies (utlined belw). These will be led thrugh an advisry gvernance structure f key partners that will als include links t existing relevant advisry structures including Clinical Cuncils and the Sunshine Cast Integrated Care Alliance. Palliative Care Crdinatr psitins (up t 2.5 FTEs), will be appinted acrss the PHN regin, based in the Central Queensland, Wide Bay and Sunshine Cast areas, with senir management versight f these psitins. The Crdinatrs will wrk cllectively t plan and implement the key strategies utlined belw t ensure cnsistency acrss the regin and share knwledge and expertise. They will frmalise an interagency steering cmmittee in each f the three areas and agree Terms f Reference (TR) and an area level plan with each cmmittee. The Crdinatrs will als wrk clsely with the Natinal Evaluatr (frm 2018-19) prvided by the Department f Health (the department) t infrm the Key Perfrmance Indicatrs (KPIs) and the prvisin f data t infrm the natinal evaluatin f the Measure. As part f ur cmmissining apprach, the PHN has defined where we prcure health services; where we partner with ther agencies t implement health system slutins; and where ur staff prvide health system supprt services (e.g. general practice supprt, allied health engagement, 2
educatin, digital health leadership). This apprach allws us t prvide clarity and transparency t ur stakehlders. This activity wrk plan uses this methd. PAL-P1: Imprve access t safe, quality palliative care at hme and supprt EOLC systems and services in primary health care and cmmunity care. Prvide: PAL-P1.1 - Imprve access t safe, quality palliative care services at hme by scping existing health care services f available EOLC acrss ur PHN regin. This will include Abriginal and Trres Strait Islander, Culturally and Linguistically Diverse (CALD), Residential Aged Care Facilities (RACFs) and hard t reach ppulatins in rural and reginal areas. PAL-P1.2 - Scping public awareness f available EOLC services acrss ur PHN regins, including Abriginal and Trres Strait Islander, CALD, and hard t reach ppulatins and imprve public knwledge f end f life care. PAL-P1.3 - Create effective cmmunicatin strategies and advcate fr quality palliative care at hme where needs fr pririty areas are identified. Partner: PAL-P1.4 - Wrk cllabratively with Hspital and Health Services (HHS) and nn-gvernment primary and secndary health care prviders in ur regin t frmalise an interagency steering cmmittee (in each area) and ensure activities align/cmplement natinal and state strategies. PAL-P1.5 - Under the guidance f an interagency steering cmmittee, identify gegraphic htspts thrugh prcess mapping EOL services and cllecting identified data sets t mnitr the impact acrss the indicatrs. PAL-P1.6 - Prmting EOL HealthPathways f care t imprve the patient jurney and experience f care at hme. PAL-P1.7 - Strengthen current palliative and EOLC mdels f care fr each specified area. PAL-P1.8 - Engage with GPs and practice nurses and cmmunity health services t identify clients wh will require palliatin (e.g. prmting the 'surprise' questin with GPs) and encurage the use and uptake f best practice t prmte Advance Care Planning (ACP), tls and resurces. 3
Prcure: PAL-P1.9 - Prvide funding fr Palliative Care Crdinatr psitins t cmplete all related palliative care EOL strategies within funded perid (Jan 2018-June 2020). PAL-P1.10 - Surce and prcure EOL training and educatin thrugh peak bdies and ther training prviders. This refers t wrking with peak bdies and rganisatins wh prvide evidence-based and accredited educatin and training (e.g. PEPA, Advance Care Planning Australia and Palliative Care Qld). We wuld wrk cllabratively with them t prmte and supprt clinicians t attend and participate in palliative care and EOL wrkfrce initiatives t build their skills and cnfidence t prvide at hme medical care. PAL-P2: Enable the right care, at the right time and in the right place t reduce unnecessary hspitalisatins. Prvide: PAL-P2.1 - Create effective cmmunicatin strategies (fr identified cmmunity target grups) t prmte the right care, at the right time t reduce unnecessary hspitalisatins. PAL-P2.2 - Create effective cmmunicatin strategies t advcate the right care at the right time t GPs, allied health services and ther related service prviders. Partner: PAL-P2.3 - Assist in prviding infrmatin and resurces t supprt service prviders t build patient and families understanding f the benefits f palliative care and knw where and hw t access hme services (bth clinical and nn-clinical). PAL-P2.4 - Assist clinicians t imprve referral criteria and prcesses fr care c-rdinatin services t reduce unnecessary hspitalisatins and increase at hme care ptins. PAL-P2.5 - Strengthen lcal mdels and share with health prviders alternative ptins that are based n evidence and best practice and align with state-wide and natinal strategies (including digital health ptins). PAL-P2.6 - Identify key partners fr example, peak rganisatins (e.g. Advance Care Planning Australia) t assist in EOL including ACP cllabratin t increase uptake f ACP guidelines, increase ACP educatin (e.g. building capacity and awareness). 4
PAL-P2.7 - Identify and build wrkfrce capacity thrugh a range f training and upskilling prgrams in cnsultatin with peak bdies and lcal service prviders (see strategy 6). PAL-P2.8 - Facilitate cnsultatin between pharmacists and health prviders t ensure medicatin safety and security including systems in place that better enable prmpt access t medicatins and mre streamlined prescribing and supply fr patients in RACFs and fr patients receiving care at hme. PAL-P2.9 - Wrk twards develping prtcls with ambulance services t develp a palliative apprach. PAL-P3: Generate and use data t ensure cntinuus imprvement f services acrss sectrs. Prvide: PAL-P3.1 - Identify baseline data that aligns with natinal indicatrs. PAL-P3.2 - Develp service-mapping tl/s t capture service infrmatin, which can be mapped by LGA and back t the PHN health needs assessment. PAL-P3.3 - Share data/infrmatin with interagency steering cmmittees and identify ther surces f data that will ensure cntinuus imprvement f services. Partner: PAL-P3.4 - Utilise existing relatinships with service prviders t map the current data landscape and identify pprtunities fr further develpment. PAL-P3.5 - Liaise with relevant stakehlders t cntribute data t gain a cmprehensive understanding f prgress against natinal KPIs. PAL-P3.6 - Link with Clinical and Cmmunity Advisry Cuncils and Integrated Care Alliance t prvide regular updates n data cllectin pprtunities. PAL-P4: Utilise available technlgies t prvide flexible and respnsive care, including care after usual business hurs. Partner: 5
PAL-P4.1 - Partner t build cmmunity and health care service cmmunicatin and technlgy strategies t increase awareness, uptake and meaningful use f My Health Recrd fr cnsumers and health prviders. Prvide: PAL-P4.2 - Use HealthPathways t map existing EOL services (including primary and secndary services) t identify service gaps within ur PHN regin. PAL-P4.3 - Prmte clinical and referral pathways and imprve wrkfrce uptake and use. PAL-P4.4 - Prmte existing technlgies e.g. access t the Viewer (HHS initiative). Prcure: PAL-P4.5 - Investigate digital health/after hurs and respnsive initiatives (current After Hurs activity; investigate pssible expansin with specialised palliative care prviders t reduce the rate f emergency department palliative care attendance). PAL-P5: Increase cmmunity capacity building (e.g. Cmpassinate Cmmunities Netwrk) within ur PHN regin. Partner: PAL-P5.1 - Prmte the benefits f palliative care and build cmmunity capacity, leveraging existing wrk with ther prviders (e.g. SCHHS Cmpassinate Cmmunities cnsultatin initiatives). PAL-P5.2 - Participate in existing HHS EOL cmmittees t explre current Cmpassinate Cmmunity activities. PAL-P5.3 - Assist t imprve levels f health (death) literacy and understanding t include ACPs. PAL-P6: Increase Wrkfrce Develpment and Capacity. Prvide: PAL-P6.1 - Imprve EOLC wrkfrce develpment by; 6.1.1 Undertaking a targeted learning needs assessment t identify areas fr develpment in EOLC 6
Partner: 6.1.2 Using the results frm the learning needs assessment, prvide General Practice and Practice Nurses with supprt t deliver effective EOLC including fr example; a) Prviding a range f infrmatin including symptm management and ACP guidelines b) Increasing the use f the palliagedgp tl c) Advcate t adjust medical sftware t include the surprise questin (75+ health check, dementia and chrnic disease templates) d) Building the skills t identify clients wh will require palliatin thrugh the increased uptake and awareness f decisin supprt tls and resurces (e.g. HealthPathways, My Health Recrd and meaningful use and effective use f MBS items) PAL-P6.2 - Prvide supprt t GPs, RACFs, QAS and HHS t adpt standardised prcesses fr dcumentatin fr ACPs and Transfer f Care between health sectrs. Ratinale/Aim f the activity The updated Natinal Palliative Care Strategy 2017 Draft 2.1 and the Natinal Palliative Care Strategy 2010 are evidence-based dcuments that can be used by peple and rganisatins at all levels f the cmmunity and service system seeking t imprve the experience f palliative care. The strategies recmmend key appraches and imprtantly recgnises fr example, that services are persn-centred and include scial, emtinal, cultural and spiritual aspects in a variety f clinical and nn-clinical settings and frm prfessinal and nn-prfessinal prviders. Cnsultatin with clinicians and cmmunity sectr rganisatins thrugh the Clinical and Cmmunity Advisry Cuncils has drawn n evidence-based research and practice in the develpment f the AWP Strategies. Where t Research prvides research and recmmendatins int GPs attitudes and appraches twards evidence based palliative care (including the use f ACP in general practice). Our PHN has used this research and recmmendatins t develp Strategy 3 abve. Strategic Alignment The strategies utlined have a direct link with the PHN Prgram s bjectives and ur PHN s Health Needs Assessment as they aim t ensure the needs f thse at risk f pr utcmes are better met, and that patients receive the right care in the right place at the right time. We have included 7
strategies that will bth identify service gaps fr patients with palliative and EOLC needs and prvide GP supprt t reduce unnecessary hspitalisatins (including digital health strategies). Scalability Thrugh a mnitring and evaluatin prcess and cnsulting with key stakehlder, we can assess the effectiveness f the strategies thrughut the life f the prject. We can identify key barriers and enablers t scaling up and cnsider the ptential reach, adptin and impact f any identified initiatives and these wuld need t be cnsistent with natinal and state plicy directins. Target Ppulatin Lcal HHS specialists, cmmunity service prviders frm NGO sectr, private sectr, GPs, nurses and RACFs. Cmmunity scial netwrks- we will partner with the HHS and ther key cmmunity netwrks/rganisatins (e.g. t build Cmpassinate Cmmunities Netwrks). Identify ppulatins within RACFs wh require ACPs. Identify ppulatins within GP wh require EOLC supprt including ACPs. Identify pririty ppulatins (e.g. Abriginal and Trres Strait Islander, CALD, lder persns). Cverage Our PHN regin has an estimated resident ppulatin f 842,057 persns, with an average annual grwth rate f 1.5 percent ver the past five years. Abriginal and Trres Strait Islander Australians numbered 29,567 r 3.5 percent f the regin s ppulatin. This percentage is slightly belw the State figure f fur percent. Within the regin, Wrabinda had the largest percentage f Abriginal and Trres Strait Islander peple at 94.4 percent. Implicatins fr service delivery: Currently, there are shrtfalls in in-hme care, cmmunity care, residential aged care and palliative care services acrss the regin, especially in the castal cmmunities. These shrtfalls are expected t increase as the regin s ppulatin ages and mre peple mve t the cast t retire. Future investments in aged care services and facilities will need t be capable f adequately addressing the changing service needs f lder residents thrughut the regin. Anticipated Outcmes Crss-sectral cllabratin will result in increased awareness f EOLC and ACPs amng targeted grups (e.g. RACFs, general practice and cmmunity). Streamlined and standardised transfer f care infrmatin and systems between service prviders (e.g. between RACFs, Queensland Ambulance Service and secndary care settings). 8
Prfessinal develpment initiatives prvided in cnsultatin with peak bdies t braden the understanding f palliative care with service prviders t include cultural safety and hlistic cncepts f health. A clearer understanding f the barriers and unmet needs in accessing services in identified gegraphical areas and fr sme ppulatin grups including Abriginal and Trres Strait Islander and CALD grups. Measuring utcmes Sme anticipated utcmes include: PAL-P1: Imprve access t safe, quality palliative care at hme and supprt EOLC systems and services in primary health care and cmmunity care. Number f GPs wh are supprted with uptake f MBS items fr EOL and Palliative care Map f number f at hme palliative care services available within ur regin (including: break dwn int LGA) Number f partnerships established with HHSs, nn-gvernment, primary and secndary health care prviders in ur regin Map f EOL services available within ur regin palliative care crdinatrs in place (up t 2.5 FTE) PAL-P2: Enable the right care, at the right time and in the right place t reduce unnecessary hspitalisatins. Number f identified partnerships/stakehlders that are included in the develpment and r utilisatin f the cmmunicatin tls Cmmunicatin plan created t advcate fr quality at hme palliative care Number f HealthPathways develped and utilised relating t EOLC PAL-P3: Generate and use data t ensure cntinuus imprvement f services acrss sectrs Agree baseline measure f planned at hme deaths with key stakehlders Establish baseline (with key stakehlders) fr number f ACPs in RACFs Identify baseline measure fr ver 75s medicatin management reviews (RACFs/ cmmunity) 9
Develpment f a service mapping tl t enable LGA mapping PAL-P4: Utilise available technlgies t prvide flexible and respnsive care, including care after usual business hurs Number f My Health Recrd ACP uplads Establish baseline f clinical pathways and referral pathways fr EOLC Number f new GPs access t the Viewer (HHS initiative) PAL-P5: Increase cmmunity capacity building within ur PHN regin. This activity is an explratin f the Cmpassinate Cmmunity s mdel and hw this may aid the bjectives in the GCfaHPC. PAL-P6: Increase Wrkfrce Develpment and Capacity. Cmpleted wrkfrce/rganisatin scping exercise Numbers f educatin resurces n EOLC prvided t general practice and RACFs A learning needs assessment tl develped Number f educatin sessins prvided t Residential Aged Care Facilities (RACF) staff and general practice arund EOLC and ACP. Indigenus Specific Abriginal and Trres Strait Islander care will be integral t the wrk undertaken with the interagency steering cmmittee grups. Palliative Care Crdinatrs will wrk clsely with key Abriginal and Trres Strait Islander rganisatins, general practices and lcal cmmunity t understand the palliative and EOLC cultural needs f Abriginal and Trres Strait Islander peples. Evidence based resurces and infrmatin will be surced thrugh palliative care peak bdies including Care Search Palliative Care Knwledge Net t supprt health prviders prviding care fr patients, family and cmmunity. Lcal issues and pprtunities will be discussed thrugh the Clinical Cuncils and Cmmunity Advisry Cuncils t develp sustainable imprvements in the quality f EOLC. 10
Cllabratin/Cmmunicatin Timeline The PHN has well established links int the lcal cmmunity and health prvider netwrks. Regular frums currently cnvened by the PHN wuld be a key surce f EOLC-specific input t imprving service delivery in this area. Examples f these include: Cmmunity Care Supprt Netwrk (80 cmmunity aged care service prviders n the Sunshine Cast); Gympie Cllabrative Netwrk (40 Gympie cmmunity service prviders); Gympie Aged care subgrup; Cmbined Health Agency Grup (Sunshine Cast); Senirs Netwrk fr service prviders and an annual frum (Bundaberg); Aged Care Cmmittee (Capricrn Cast), Integrated Care Alliance (Sunshine Cast 31 members frm 12 rganisatins). In each area (Central Queensland, Wide Bay and Sunshine Cast) interagency steering grups wrk in partnership with EOLC prviders t develp sustainable mdels f care. Members fr the cmmittees are selected using an expressin f interest prcess and thrugh lcal discussins with the HHS. Members will be expected t cntribute t the lng term visin f; Scping the gaps that relate t the key pririty areas t imprve and increase at hme palliative care services Supprt the current wrk f the HHS and cllecting EOLC specific cmmunity and cnsumer input t strengthen the mdel within the regin Identifying service and data develpment pprtunities t supprt a mre integrated mdel f patient centred care. Each Palliative Care Crdinatr will prvide utcme reprts t the Clinical Cuncils in each area and mre detailed reprting prvided t the PHN. Members f the interagency steering grups prvide feedback t their respective rganisatins. Milestnes Start Finish Cmpleted Activity Wrk Plan January 2018 February 12 2018 11
Palliative Care Crdinatr psitins recruited January 2018 End March 2018 Internal PHN planning with Palliative Care Crdinatrs and lcal prject plans cmpleted in line with AWP April 2018 End April 2018 Cnsultatin with lcal EOLC prviders April 2018 Onging Palliative Care interagency steering cmmittees established and agreed prcesses fr sharing infrmatin in place. April 2018 Onging Resurces shared, surced and disseminated including relevant state and natinal EOLC strategies, plicy framewrks, legislative and clinical gvernance dcuments. Regular meetings established with ther successful PHNs t share and supprt prject implementatin. April 2018 June 2018 April 2018 June 2021 Linkage with key cnsumer and cmmunity grups acrss the regin and supprtive wrk cmmenced with Cmpassinate Cmmunities Netwrk. May 2018 Onging Learning needs analysis undertaken with health prviders t identify areas f strength and areas fr skill develpment in end f life care. Indicatrs t measure impact and prcess indicatrs develped in cnsultatin with DH Natinal Evaluatr. July 2018 Oct 2018 July 2018 June 2021 12
Data sets fr cllectin identified and wrking cllabratively with Natinal Evaluatr. Aug 2018 June 2021 Partnering with peak bdies t surce educatin and training fr clinical wrkfrce Sept 2018 Onging Mapping f cmmunity based EOL (clinical and nn-clinical) resurces cmpleted Advance Care Planning educatin and training cmmenced with RACFs, GP and cmmunity cmmenced Nv 2018 Jan 2019 Jan 2019 June 2019 Other activities t be identified thrugh the interagency advisry cmmittees. 13