Why a Winter strategy? Every winter, there is a surge in healthcare demand both in the community and hospitals. Older and frail patients are especially vulnerable during this time.

Purpose To support general practices to keep their most vulnerable patients well and reduce their likelihood of being hospitalised this winter.

Background – how did we get here? Joint Project between NNSWLHD & NCPHN to develop a whole of system strategy, to better respond to the healthcare demands over winter These initiatives have been developed in partnership a series of workshops were held between February and May to design the program involved more than 51 stakeholders from LHD, PHN, General Practice, Ambulance, AMSs and Consumers.

Winter Strategy Aims Aim 1: Improve respiratory hygiene and vaccine uptake, slowing the seasonal epidemic of infectious respiratory conditions using a population wide campaign; Aim 2: Provide Assistance and support to General Practice to facilitate a planned and proactive management of very high risk patients in the community; Aim 3: Establish an efficient and effective process for transfer of care from hospital to community during winter.

Aim 1: Population Wide Campaign Advertising campaign via social media, local radio and press, to educate community on importance of fluvax and slowing the spread of infectious respiratory conditions http://healthynorthcoast.org.au/winter-well Posters have been developed and will be available to download/print for display in your practices Fridge Magnets available for distribution to your patients. The magnets promote flu vaccination, reducing spread of respiratory conditions and key telephone contacts

Aim 2: Funding and Supports for General Practice We will provide general practices with funding and resources to identify and support at risk patients. The program will be offered from July 1st until 29th October 2017. Places are limited to 1000 patients. More details about this aim and what it means for you at the end of this presentation

Aim 3: efficient and effective transfer of care from hospital to community during winter Improved Discharge Planning, involving patient, carer and GP in discharge planning Improved communication with GPs at admission Making appointments for patients >70 years, with their general practitioner, prior to discharge

NNSW LHD Chronic Disease Team presentation

The Practice Nurse Role

What’s involved? Create a winter watch list Adult patients (Aged >18 years) with one or more condition who are likely to benefit from heightened care are eligible. Palliative Care patients, and those enrolled in CVC are excluded Watch list patients will be registered using a simple process

What’s involved? Monitor watch list patients throughout winter and ensure: Health conditions and care plans have been recently reviewed Self-care is promoted and winter watch patients each have a sick day action plan Patients are monitored regularly by the practice team Specialist services are involved if needed There is a contact person at your practice for each patient so they can discuss concerns and receive care in a timely way

What’s involved? Participate in evaluation Short survey of registered patients, GPs and PNs Weekly data submission using a simple online process Interview with evaluators at the end of the program

What we are offering NCPHN will provide payments to help practices meet additional costs Funding will be available to allow practices to refer registered patients to allied health where needed to prevent hospitalisation (Conditions apply) A range of other supports to keep at risk patients winter well.

How it works- Practice Payments Practice nurses will have a key role to play and NCPHN will provide payments to help practices meet these additional costs. Payments are calculated on the basis of a hourly rate of $37.00, and will be made fortnightly, upon submission of data. 1 hour nursing payment for every patient registration submitted. (This recognises the need for a long appointment, often undertaken by nurses to assess patient needs, develop a plan and complete registration activities.) $11.10 per week for each registered patient, available from the 1st July until the 29th October (17 weeks).

Example: A patient registered by the 1st of July, who remains in the program for the full 17 weeks would attract a payment of $225.70 (Plus GST)

How it works- Allied Health Funding New funding will be available to practices to refer registered patients to allied health, where the service cannot be accessed via: Local Health District; EPC items; Health Insurance or private payment. General Practitioners can submit a request for payment to NCPHN that will be approved within 1 working day to eligible patients. Once approved, the practice arranges the allied health service and provides a referral. NCPHN will pay the provider directly

How it works- Other Supports Assistance to identify patients at risk of being hospitalised over winter Resources to support development of sick day action plans. Links to specialist chronic disease management nurses from the Local Health District. Instant electronic notification if your registered patient is admitted to, or discharged from, hospital. Referral to Hospital in the Home, available 7 days per week Patient resources to use in your practice. We will collect, publish and share great tips and tools including ideas collected from other participants

The nitty gritty questions… Practice enrolment opens on the 31st May Patient registration opens soon Patient registration will close when all places are filled. Data submission will be a simple online form, sample available soon Payment will occur automatically, based on the number of patients you submit data for. No invoicing required. As long as you submit data, payment will be made- it is not linked to the amount of service you provide Practices decide how they want to organise their team to deliver the care – the payment does not have to be used only for nursing

Further Information For more information and to enrol your practice visit www.ncphn.org.au/winter-2017