Indigenous Australians Health Programme

Integrated Team Care

Activity Work Plan 2017-18

DDWMPHN Integrated Team Care AWP 2017-18 2

Contents

1. DDWMPHN OVERVIEW………………………………………………………. 3

2. STRATEGIC VISION FOR INTEGRATED TEAM CARE FUNDING…….. 6

3. PLANNED ACTIVITIES FUNDED UNDER INTEGRATED TEAM CARE FUNDING SCHEDULE………………………………………………………….. 8

ITC_1.0_201718 - Integrated Team Care…………………………………………….. 8

DDWMPHN Integrated Team Care AWP 2017-18 3

1. DDWMPHN Overview

STRATEGIC VISION:

The Darling Downs and West Moreton PHN region covers the major Queensland communities of Ipswich and Toowoomba, plus the surrounding rural communities of the Lockyer Valley, Boonah (Scenic Rim), Esk (Somerset), South Burnett, Southern Downs, Goondiwindi and the Western Downs (Dalby, Chinchilla, Miles and Tara). The PHN region covers two Hospital and Health Service areas, ten local government areas (or parts thereof), nine Australian Statistical Geography Standard (ASGS) SA3 statistical areas (or parts thereof) and 64 SA2 statistical areas.

We exist as a PHN to support primary health professions through reform activity that delivers better health outcomes for the Darling Downs and West Moreton community. We seek to ensure that people in the Darling Downs and West Moreton region enjoy optimal health and wellbeing through accessible to a responsive, integrated and high quality primary health system.

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To achieve our strategic vision, we will:

Better understand the health needs of the DDWMPHN community through comprehensive, ongoing analysis and planning, in collaboration with the general practice, the primary health sector, Hospital and Health Services, the social sector and the community.

Achieve best value for money, by considering service gaps and the needs of the community, to work with service providers to augment and/or increase their delivery.

Optimise genuine collaboration and integration of general practice, hospital and health services, allied and mental health services, and other service providers by focussing on the social determinants of health and wellness.

Deliver of responsive, focussed practice support to create a regional primary health environment that continues to provide high quality, efficient and accessible health care to individuals and communities in our region.

Provide useful and appropriate support to ensure primary health professionals are best placed to provide care to patients subsidised through the Medicare Benefits Scheme (MBS) and Pharmaceutical Benefits Scheme (PBS) with a focus on reducing emergency department presentations and avoidable hospital admissions.

Assist primary health services and the broader community to understand and use digital health systems in order to optimise the secure flow of patient information across the health provider community.

Commission, and decommission, service delivery through active and genuine co-design, innovation and good governance.

VISION:

A seamless healthcare system that fulfils the needs of Primary Health Care Providers and the Community.

PURPOSE:

With a strong focus on primary and integrated health care, we believe that, by bringing the Darling Downs and West Moreton health community together we can significantly improve the health outcomes of our community. We are better when we achieve things together!

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VALUES:

FOCUS AREAS:

GOVERNANCE:

In addition to the Board of Directors, the Governance Framework for DDWMPHN includes Clinical Councils, Community Advisory Committees and Mental Health / AOD Sub-Committees for both West Moreton and Darling Down regions, along with an Antimicrobial Taskforce for the Darling Downs region.

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2. Strategic Vision for Integrated Team Care Funding

The DDWMPHN Integrated Team Care (ITC) Activity Work plan is developed in consideration of the population and health status profile of Aboriginal and Torres Strait Islander people identified in the DDWMPHN Needs Assessment. The strategic vision of the DDWMPHN is to be a lead enabler for primary health care, to close the gap and achieve improved health and wellbeing for our Aboriginal and Torres Strait Islander people. It is recognised that the Aboriginal and Torres Strait Islander population in the Darling Downs and West Moreton regions experience poorer health and greater exposure to risk factors than other Queenslanders. This drives a crucial need for us to establish strong partnerships with existing Aboriginal Health Services, Hospital and Health Services, public practices and enable new and innovative enterprises to be considered via a robust commissioning framework. Ongoing evaluations, both internally and externally, with our Clinical Councils, Community Advisory Committees, consumer groups and partners has been a catalyst for improvements and enhancements in activities and programme opportunities since the DDWMPHN’s commencement. We will continue, throughout this funding period, to implement, evaluate, adjust and monitor ensuring the provision of programmes is positively impacting individuals, families and communities. The DDWMPHN has a dispersed geography, cultural nuances and considerations that we will focus on to deliver our strategic vision: Creating objectives that are aligned to current evidence and data on the health

challenges and outcomes for Aboriginal and Torres Strait Islander people; Regular review of current performance and opportunities, with a focus on building

strong partnerships with Aboriginal Medical Services and other Indigenous services. Culturally appropriate and connected communication, commissioning and

implementation approaches Real, engaged and driven partnerships with Aboriginal and Torres Strait Island

communities, providers, leaders and elders. Innovative and governed commissioning and contracting mechanisms Operationally the DDWMPHN are committed to strengthening our strong governance framework and workforce capability and expertise to effectively oversee delivery, performance and outcomes as identified in the DDWMPHN Needs Assessment.

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DDWMPHN strategy has been to ensure ongoing provision of ITC programmes is focused on minimising disruption to services for clients, maintaining the continuity of the workforce, and continued referral pathways for GPs and Aboriginal health services. Within this next funded period, we are focused on:

Critically reviewing and evaluating the performance of our current ITC programmes. This will require establishment and implementation of a quality framework to assess treatment and management of chronic health conditions across our lead network.

Increasing ITCO/IOW coverage to provide greater provision of supplementary services Implementation of an innovative, transparent and accountable commissioning process

enabling right care, right place, right time in different areas and new ways. Enhanced access realised via the commissioned service network with emphasis on

targeting communities with higher needs (as indicated in the Needs Assessment) Development and participation in an end-user service testing to enhance service design Delivery of high impact information, resources, training and guidance to mainstream

primary care services to continue to enhance culturally appropriate services. The aim is to increase the uptake of Aboriginal and Torres Strait Islander specific Medicare Benefits Schedule (MBS) items including Health Assessments for Aboriginal and Torres Strait Islander people and follow up items.

Liaison and partnership with PHN’s on DDWMPHN boundary (i.e. Western Qld PHN, Brisbane North PHN, Brisbane South PHN, Gold Coast PHN, Hunter New England and Central Coast PHN) in order to respectfully address Aboriginal and Torres Strait Islander groupings and tribal affiliations for consistent primary care service access.

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3. Planned Activities Funded Under Integrated Team Care Funding Schedule

ITC_1.0_201718 - INTEGRATED TEAM CARE

ITC Transition Phase

With a focus to ensuring ongoing continuity of care for Aboriginal and Torres Strait Islander people in our region, DDWMPHN has continuing contractual arrangements with Aboriginal Medical Services (AMS). The DDWMPHN continues to work closely with the AMSs in the Darling Downs and West Moreton region to ensure their ongoing sustainability and strength.

Is the PHN working with

other organisations

and/or pooling

resources for ITC? If so,

how has this been

managed?

To build the capacity and independence of AMS and Indigenous organisations across the Darling Downs and West Moreton region, the DDWMPHN will seek to develop a ‘preferred provider’ status with organisations to deliver specific health services to Aboriginal and Torres Strait Islander people.

The DDWMPHN will work across the primary health sector in the Darling Downs and West Moreton regions to ensure full and active engagement in the development and execution of the plan. In addition to working with the AMS sector, the DDWMPHN will engage with mainstream general practice, the allied and mental health sectors and NFP services who are involved and/or provide services to Aboriginal and Torres Strait Islander communities.

Additionally, the DDWMPHN will work closely with the Darling Downs Hospital and Health Service and the West Moreton Hospital and Health Service to ensure active integration with Aboriginal and Torres Strait Islander services already being run within the hospitals.

The DDWMPHN will seek to increase capacity within the mainstream primary health sector via a vigorous engagement strategy. Where practical, opportunities to work with Universities and Research Institutes to focus on ensuring professionals in the primary health sector understand the complexities of Aboriginal and Torres Strait Islander health, including the significant impact of socio-economic determinants on the health of this community. No pooling of resources is being undertaken at this stage.

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Service delivery and

commissioning arrangements

The commissioning and development method considers the new services within the triple aim construct: efficiency, quality and better access across hard to reach and disadvantaged communities. The strategic intent, articulated in the DDWMPHN Strategic Plan, guides the process. ITC’s care coordination services are fully commissioned to 30th June 2018, however, it has been agreed that the DDWMPHN will transition supplementary services to the preferred providers as financially appropriate* within their region by 1st January 2018. Management of Supplementary services has been contracted to some AMSs and will continue to support others with their effort to continue to build their capacity to achieve recorded improvements in the management of the ITC programme in their service locations. *Provisions of support may be required for particular providers and the DDWMPHN will alert the Department of Health where supplementary services funding requires specific provision.

Decision Framework

An Aboriginal and Torres Strait Islander Health Priority Action Group was considered however, after initial consultation with Stakeholders and Aboriginal and Torres Strait Islander communities, the idea of creating a duplication of expertise would provide no further benefit to planning.

DDWMPHN has allocated a key staff member a project to determine the current groups/ bodies in existence who can be accessed to design, consult, commission and evaluate the ITC Framework and associated activities through: o Mapping of all Aboriginal & Torres Strait Islander specific

services town by town across the region

o Providing a general overview of obvious service duplications and gaps

o Researching, and devising using research, Literature Reviews and evidence-based strategies used to improve health outcomes for Aboriginal and Torres Strait Islander People in

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Mental Health, AODs, Chronic Disease, Suicide Prevention and Disability and Aged Care.

o Reviewing current PHN involvement (nationally) activities/projects for combining traditional and cultural healing with mainstream medicine

o Devising a commissioning policy and procedure manual for use in all Aboriginal and Torres Strait Islander EOI/Tender and procurement activities

o Ensuring all tenders and proposals have specific questions (as per guiding principles) that will appropriately check and inform all tendering and commissioning pieces

o Assisting the DDWMPHN utilise all of the above to create appropriate recommendations for inclusion of strategies/projects in ongoing AWPs

A CEOs meeting for all commissioned services for ITC and associated organisations has been scheduled prior to the end of 2017 with the aim of engaging and building consultative and transparent conversations broadly. It will consist of AMSs, Universities, and the DDWMPHN

The DDWMPHN has, and will continue to, work with the Clinical Councils and Community Advisory Committees (who include Indigenous representation) to determine the best way forward to commission services for Aboriginal and Torres Strait Islander communities. This includes, but is not limited to: o Monthly briefings with Clinical Councils and CAC;

o Ongoing consultations with Aboriginal Medical Services and other Indigenous services across the region, including regular visits by the CEO and senior staff;

o Working with the Darling Downs HHS and West Moreton HHS to integrate into the work they are doing within Aboriginal and Torres Strait Islander communities; and

o Meetings with elders, individually and as a group.

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The DDWMPHN will rely on data collected and analysed through the revised HNA and the information collated from the above ITC project to plan the DDWMPHN 2018-19 activities

Indigenous Sector

Engagement

The DDWMPHN currently has six Aboriginal Medical Services within the catchment providing services to Aboriginal and Torres Strait Islander people.

The DDWMPHN works closely with these organisations, including regular contact and visits with the CEO and executive staff, joint training sessions with AMS and ITC staff, active participation in community events such as NAIDOC Week, and information sharing through social media.

DDWMPHN will conduct service mapping activities (as per above project) to research all organisations within the region to identify organisations that have specific Aboriginal and/or Torres Strait Islander health funding and their respective referral pathways to create a network or organisation, both mainstream and Aboriginal and Torres Strait Islander, to be able to provide better access for the ITC teams and their Aboriginal and/or Torres Strait Islander communities.

Description of ITC Activity

ITC and CCSS funding has been continued through a commissioning process with the AMSs, with a focus on continuity of care.

The DDWMPHN ITC team continue to work closely with the AMSs within the region to ensure that patients receive appropriate services as per the programme guidelines.

In 2017/18 as promised, the DDWMPHN has undertaken a review process to ensure an optimal ITC model is being administered based on the needs presenting in the region. This review highlighted the need to re-design the DDWMPHN internal workforce allocation and partner far more closely with providers. This has resulted in a supplementary service handover where financially appropriate, along with key changes to engagement and working relationships

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The review will see significant activity in engaging mainstream practices, indigenous organisations, enhancement of commissioning processes and robust evaluations of outputs and outcomes from January to June 2018.

The DDWMPHN has: o Re-contracted existing providers under the ITC programme.

This will continue to maintain the continuity of care for Aboriginal and Torres Strait Islander people while the review and development of the Plan is undertaken.

o Reviewed alignment of current services as per ITC Guidelines. The refreshed Health Needs Assessment will be used to inform considerations for the most effective and culturally appropriate programmes moving forward

o Reviewed best practice approaches for the delivery of ITC services by other PHNs in Australia.

o Consulted with current providers, general practice, other mainstream health services/professionals and AMS on possible service options. This consultation resulted in internal workforce changes to maximise mainstream capability particularly in rural locations. It is clear from the review, there is a need to develop refined service specifications and consult with providers and other organisations to commission services beyond June 2018

ITC Workforce

The DDWMPHN ITC team will continue workforce support and training activities for the ITC workforce and commissioned providers across the region. This includes regular training days where the team collaborate across organisations to provide support and information.

Community Engagement

The DDWMPHN will conduct a series of community engagement events across the region to identify local:

Aboriginal and Torres Strait Islander health needs, Gaps in services, Barriers to accessing primary health care, Community led activities that are working toward better health With the information gathered at these events DDWMPHN will:

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Build upon the current HNA Identify local organisations that can be upskilled to address any

needs and/or barriers raised Consider current funding models to address needs and/or gaps at

the local level Build the capacity of local organisations/groups to enhance local

community activities addressing health needs