Gold Coast Complex Care Project (MyHealth) Welcome and explanation of who is who Content: Rationale for the project Where it fits within the Gold Coast Population Health Project, research agenda Overview of the project Overview of roles of admin, nurse and doctor Focus on examples from GP experience in multimorbidity of prevention, deprescribing, coding, using Care Plan for coordination, patient safety Conclusion and reminder of key role as ‘credibility lead’ Presentation developed Dr Mark Morgan Associate Professor Bond University, Eastbrooke Family Clinic, Gold Coast

Acknowledgements This presentation was developed by Dr Mark Morgan Associate Professor Bond University, Eastbrooke Family Clinic, Gold Coast MyHealth Collaborative team, Centre of Research Excellence Mark Morgan, Chris Healey, Kevin Mc Namara, Kate Schlicht, Michael Coates Gold Coast PHN team and Dr Evan Ackermann Mudgeeraba General Practice, Harmony Health Medical Centre, Mermaid Central Medical Clinic, On The Park General Practice

Fred Too much medicine Reducing over-treatment de-prescribing de-specialising de-intervening

Over 75 Health Assessment GP team New GPMP/TCA Review 1 Plus seasonal focus Review 2 Review 3

GP Management Plan My Story My values My goals If my health deteriorates Medical goals Advanced Health Directive My Health Summary & Measures

Seasonal Focus

http://www.polypharmacy.scot.nhs.uk/ Search ‘Scotland’ ‘polypharmacy’

Research outcomes

Example – Tier 4 intervention Avoidable admissions for people aged 75+ 4 practices, 4 different software packages Through facilitated co-design process all 4 agreed on: common template to support 75+ health check common complex care plan template aligned to MBS items Through our data platform: 177 high risk patients 400 moderate risk patients recalls commenced care plans being completed new needs being addressed Recruited 4 practices with 4 different common GP software packages Practice support staff undertook co-design process, ensuring everything aligned to existing MBS item number requirements and agreed health care check and care plan templates. Data which is deidentified before leaving the practice brought into the platform (the primary sense tool) to look at key data items already sitting in practice software data which may indicate patients at risk. Indicated a total of 177 high risk patients, 400 moderate risk patients and this is fed back to practices. Once back in practice at risk patients can be reidentified, by the practice, and this can inform recall of the at risk patients. Practices are currently recalling patients and at least 16 have occurred at one practice and indications are that it is likely the other practices will have similar numbers. Early feedback from clinicians is this process is uncovering a range of previously unknown issues for patients including social issues, a major factor in avoidable admissions for this age group which they begin to intervene

Thank You Further information http://www.phcris.org.au/researchevidence/item.php?id=8421&spindex=18 and Gold Coast PHN