1. BetterLinks care planning in a multi- disciplinary practice model Upper Hume Primary Care Partnership

2. Better Links – why?  Lead Agency model for complex clients  New Medicare Team Care Arrangement items introduced in July 2005.  Integrated Chronic Disease new deliverable for PCP Our focus: To discover current practice and develop a best practice model to provide better outcomes for clients in a system of care – specifically diabetes. To discover current practice and develop a best practice model to provide better outcomes for clients in a system of care – specifically diabetes.

3. Better Links – who was involved Steering group Border Division of General Practice – CEO & Practice Support officer Border Division of General Practice – CEO & Practice Support officer Upper Hume PCP - Executive and Service Coordination officers Upper Hume PCP - Executive and Service Coordination officers Wodonga Regional Health Service - Manager of Allied Health Wodonga Regional Health Service - Manager of Allied Health Better Links Project Officer Better Links Project Officer Reference group of clinicians/practitioners Reference group of clinicians/practitioners Membership included GP Practice Nurses, optometrist, dietician, private podiatry practice nurse, GP practice manager, private pharmacist, diabetes educators.

4. The context Public providers Private providers NSW Victoria Medical Allied Health No HARP-CDM program No E-referral New Medicare items at July 2005 Community Commonwealth

5. Barriers to information flow and clarity in roles and responsibilities:  funding-based barriers  ideological boundaries  organisational models and capacities  professional models  paid workers vs volunteers  complexities of the social support system  Lack of repository of knowledge for clinicians PERHAPS a KEY ENABLER is a clinician's non-clinical skills

6. Method - how  We tracked data flow between services for type II Diabetes clients.  We evaluated existing models and compared practice and theory Identified our assumptions Developed a definition of ‘effectiveness’ and ‘sustainability’ (success factors) for Care coordination Developed a definition of ‘effectiveness’ and ‘sustainability’ (success factors) for Care coordination Client scenarios – use of client files Client scenarios – use of client files Data flow analysis of activity – referral and feedback Data flow analysis of activity – referral and feedback Defined a draft model Defined a draft model

7. We learnt  Client pathways not clear  GPs & allied health liaise well – but not with others  Confusion about funding for allied health via TCAs  Not all GPs using TCAs  Lead Agency & GP Care Planning models compatible on paper …  Lead Agency model – informal, ad-hoc  Need standard methods/tools – public & private  Strong culture of support in finding a service  Gaps when it gets complex

8. What Models …………….. Critical factor is SUPPORT to negotiate system when client needs are complex across medical and social issues. Life coach…..??

9. Recommendations  Support dedicated practice nurse roles in general practice care planning for CDM  Position(s) be nominated / created responsible for non-medical care coordination in the community  MUST include service paths and options for both Private and Public services  GP care planning be supported by education, common service directory and tools  Devise mechanism to support general practices without facility to employ CDM practice nurses in participating in GP CDM

10. Opportunities - Next steps - Define pathways for those with newly diagnosed diabetes II - Agreements on pathways for care planning – include private/public and social - Support general practice to use e-referral system - Build on initiatives occurring - Invest in relationships between all service providers

11.  Contacts Judith Moore Upper Hume PCP 02 6022 9284 Judith Moore Upper Hume PCP 02 6022 9284 jmoore@wodonga.vic.gov.au jmoore@wodonga.vic.gov.aujmoore@wodonga.vic.gov.au Trevor Cowell Border Division 02 6049 1900 Trevor Cowell Border Division 02 6049 1900 Sue Thomas Wodonga Regional Health Service 02 6051 7111 Sue Thomas Wodonga Regional Health Service 02 6051 7111 See www.upperhumepcp.com.au ‘projects’ for the full report. www.upperhumepcp.com.au