1. GP Referrals into the Stawell Health & Community Centre (SH&CC) A joint project: Grampians Community Health Stawell Regional Health Grampians Medicare Local (formerly WestVic Division of General Practice) Stawell Medical Centre Patrick Street Family Practice Sloane Street Medical Practice Budja Budja Medical Clinic - Halls Gap

2. Area Map

3. Stawell Health & Community Centre

4. Opportunity knocks… Co-location GP comment Meeting called late 2010

5. What GP’s Wanted One point of referral Guaranteed delivery List of services available Confidence in service Auto populating referral form Feedback

6. What Service Providers Wanted Improved communication Increase in quantity and quality of GP referrals Easier system for clients Long term aim  electronic capability  Integrated and coordinated care

7. Work To Date… Capitalising on existing centralised intake. Intake had undergone review. GP referrals sent to a secure fax. Administration staff acknowledge, record and disseminate G.P referrals sent to appropriate worker. Organisational policy/procedure on service response is activated. Development of agreed processes.

8. Grampians Community Health Intake Flow Chart

9. Referral Template Use template GPs are familiar with Expand to include all services Medicare Local embedded tool in practice software Auto populate

10. G.P Feedback Generic feedback tool GPs are familiar with Based on State-wide Service Coordination guidelines for G.P feedback

11. SH&CC Flow Chart for G.P Referral Feedback

12. First Review of Referral System Modifications made at the first review Referral acknowledgements Practice found the referral acknowledgements an annoyance and were discontinued. The practice relies on the fax machine report alerting them to an unsuccessful transmission. Has implications with MBS items – being reviewed. Dissemination of referrals Simplified to a pigeon hole for each organisation

13. First Review Modification to G.P feedback Responding to GP needs Limited to change in condition, DNA and outcome at exit of service Alterations to referral tool and information Change language of service descriptions More information required G.P requested more information on services provided Desk top brochure developed Agreed to meet and review 6 monthly

15. Referrals from June 2012 to July 2013

16. Total Number of GP Referrals June 2012 to August 2013

17. Service Breakdown Grampians Community Health June 2012 to August 2013

18. Service Breakdown Stawell Regional Health June 2012 to August 2013

19. EIiCD Focus The Ararat and Northern Grampians Early Intervention In Chronic Disease (EliCD) Steering Committee is a voluntary alliance of agencies working across Ararat Rural City and Northern Grampians Shire to ensure a collaborative approach to the utilisation of specific funding provided by the Department of Health (DoH) for Early Intervention in Chronic Disease. Grampians Medicare Local Grampians Pyrenees PCP Grampians Region Dept Health Diabetes Education Stawell Regional Health East Grampians Health Service East Wimmera Health Service Grampians Community Health Dietetics Exercise Physio Podiatr y Lifestyle Coordinator

20. The Steering Committee developed the concept of the Lifestyle Coordinator to increase the sustainability of behaviour change and act as a conduit between the traditional ‘medical model’ and a community development empowerment approach to change, aiming to assist the client to better manage the lifestyle factors contributing to chronic disease. Using principles from Motivational Interviewing theory, the Lifestyle Coordinator role explores client ambivalence and attitudes to change and seeks to embed positive behaviours. The role is performed by a ‘non medical’ practitioner who works one-on-one in a supportive, flexible way to respond to clients’ individual needs and circumstances, an approach which reflects key characteristics of The Flinders Model of Chronic Condition Self-Management.

21. Lifestyle Co-ordinator The Lifestyle Co-ordinator aims to create links that promote better whole health outcomes for people newly diagnosed with a chronic disease by facilitating access and participation in appropriate physical activity and social engagement opportunities. The coordinator is expected to create or connect a network of opportunities to allow clients the opportunity to choose from available program. Almost 100 clients with a chronic disease diagnosis have Been referred by local GPs to this program since June 2012

22. Evaluation Opportunity WestVic Division (now Grampians Medicare Local) 30 random files from each agency audited GP referrals GP feedback

23. Stawell GP & Primary Health Service Systematic Communication 2012 Review

24. Evaluation of G.P Referrals

25. Elements omitted due to the information not being requested as an auto populated field Challenge is to keep it simple and time effective for GP’s while meeting accreditation standards Inclusion to be reviewed at next meeting

26. Evaluation of G.P Feedback

27. Medicare number most commonly omitted field – has since been included.

28. Conclusion Since the introduction of a coordinated systematic referral and intake process in 2011 by Grampians Community Health (GCH), Stawell Regional Health (SRH) and Stawell Medical Centre (SMC) the following changes have been measured: increase in documented GP referrals increase in referral quality increase in GP feedback provided increase in GP feedback quality Stawell GP & Primary Health Service Systematic Communication Report – November 2012 Review. Joanne Martin Grampians Medicare Local

29. The system and tools have been reviewed with a review scheduled biannually. Changes have been implemented with consensus from all parties. The system has now expanded to include all four medical centres: Stawell Medical Centre Patrick Street Family Practice Sloane Street Medical Practice Budja Budja Medical Centre and includes referrals to the Northern Grampians Shire HACC Services.. Conclusion

30. Positives…..the planets aligned Opportunity presented Willingness to work to common goal Agencies history in partnership work Co-location GCH Intake process review Staff acceptance of change

31. Difficulties Encountered Accessing GPs or Practice Managers to discuss services and process GP understanding of client consent and implications Not enough information from GPs to process referrals Communication and knowledge of changes in services

32. Where To From Here? Moving toward electronic transmission Conversion of fax transmission to email Interfacing Connecting Care and Argus Grampians Community Health services delivered in Ararat and Horsham areas Undertake work to include Wimmera Uniting Care (child and family services) Further refine the process

33. Contacts Katrina ToomeyKate Astbury Health Promotion Coordinator Extended Care Manager Stawell Regional HealthGrampians Community Health Sloane Street, Stawell 338060 High St Ararat Ph 5358 8611 Ph 5352 6200 katrina.toomey@srh.org.aukatrina.toomey@srh.org.au kate.a@grampianscommunityhealth.org.au kate.a@grampianscommunityhealth.org.au www.srh.org.au www.grampianscommunityhealth.orgwww.srh.org.auwww.grampianscommunityhealth.org