The Enablers Project Yin Li – Special Projects Coordinator Anne Harley – Aged and Palliative Care Coordinator

Diagnosis Results Day 1 Day 2 Day 5 Came in ready to implement our Integrated Care Project Day 1 Not enough consultation Too many assumptions Too process driven, not person centred No focus on culture or intrinsic motivators Measures were not indicative of a ‘value add’ for our target audience Day 2 Planned consultation with General Practices and their external providers Additional measures for patient and provider experience Investigate activities to promote culture change and team building based on lessons learnt from Collaboratives model Day 5 Came in with top down approach Not enough consultation Too many assumptions Too process driven, not person centred No focus on culture or intrinsic motivators Measures were not indicative of a ‘value add’ for our target audience Planned consultation with General Practices and their external providers Additional measures for patient and provider experience Investigate activities to promote culture change and team building based on lessons learnt from Collaboratives model

Rationale for Change Patients in South Western Sydney with chronic conditions experience fragmented care contributed in part by: Recording and sharing of inaccurate and unreliable patient data; Ineffective communication between members of their care team; and Care planning that is not person-centred Only 13% of patients with diabetes had there cycle of care completed and claimed correctly GP reported diabetes as the main issue reported

Overarching Aims & Objectives To improve the care and experience of our patients with chronic conditions through improved care planning within general practice that is person-centred and through improved communication between their care team members. Specifically to: Improve the accuracy and completeness of patient data Improve information sharing via secure messaging and use of My Health Record Increase practice team capacity to prepare person-centred care plans Background – SWSPHN is running a data quality improvement program Pilot enablers was run last year but not very successful, and not yet complete Clinical integration to form a foundation for other integration projects

Mission Statement South Western Sydney has high chronic disease incidence and prevalence when compared with NSW. It is folly to think that people with chronic diseases are able to receive optimal care from isolated health care professionals. Joined up, person-centred integrated care is data driven and reliant upon effective communication and care planning. As a foundational step towards integrated care, SWSPHN wishes to work with general practice and primary health providers to develop quality primary care data, seamless communication practices and coordinated care planning to positively influence health outcomes for our community members and reduce health care professional burden.

Analysis & Design Results Situational need INPUTS OUTPUTS OUTCOMES Measures   Activity Short Medium Long Recording and sharing of inaccurate and unreliable patient data QIPC program Staff time 4/12 Benchmarking reports Disease specific reports CAT training Goal setting Regular follow-up 6/52 Culture Data quality will improve Recall reminder systems improve Information that is shared is more accurate and reliable Patients receive more integrated and coordinated care % data quality improvement for recording of risk factors, coded diagnoses, medications etc. over time Situational need INPUTS OUTPUTS OUTCOMES Measures   Activity Short Medium Long Ineffective communication between members of their care team  Buying SMD licenses Staff time Internal staff training Providing/installing SMD licenses Practice staff training in SMD usage Practice staff training in MHR usage Engaging with allied health/specialist Culture – bringing GPs and their providers together to build trust Increase SMD usage (sending and receiving) Increase MHR usage (uploading SHS and viewing) Improved communication between GPs and external providers  Patients receive more integrated and coordinated Number of secure messages sent/received – can measure number of messages viewed??? Provider views Reduction in faxes and letters sent/received – can measure number of letters printed? Improved provider experience Situational need INPUTS OUTPUTS OUTCOMES Measures   Activity Short Medium Long Non person-centred care plans Cost of external trainer (CPD and train the trainer) CPD costs (catering etc.) Staff time $XX per practice payment Resource development CPD events for GPs and nurses Train the trainer Culture (team building) Practice staff training Practices to submit care plans for review Reviewing the care plans Providing feedback Increased staff capacity GPs and PNs competencies increased GP and PNs are better resourced PHN staff are upskilled More cohesive team functioning Increased provider satisfaction Patient care plans are more patient centred Practices are more engaged with PHN  Patients receive more integrated and coordinated care Reported consultation times? Report time spent working out SMD? Does it improve provider experience? Has it improved communication? Number of care plans submitted that meet quality care planning criteria Patient experience surveys Based on national voices narrative – ‘I statements’

Action Plan with Timescales When Consult with practices that participated in pilot project ASAP Consult with potential practices for the Enablers Wave 2 Bring GPs and their referrers together to build trust and co-design Create tools to support culture and team building Create patient experience and provider experience measurement tools