1. Preparing CQI Action Plans due by 31 January 2016 3 Powerpoint Tools for Improving Services along the Patient’s Journey 31 December 2015

2. CQI Action Plans of ACCHOs – Patient Journey Member ACCHOs of NACCHO are required to submit “CQI Action Plans” to the Commonwealth Department of Health by 31 January 2016. In August 2015, the Department issued a template which was “developed to align with the core components in the draft National CQI Framework for Aboriginal and Torres Strait Islander Primary Health Care that are relevant at the local service level.” There are 9 of these core components. In an accompanying “Guide to developing the Action Plan”, the Department gave examples of what to put in to their template. The Department said in its “Guide” that: “The primary focus for CQI activity is the service being provided to Aboriginal and Torres Strait Islander people. The patient experience and the quality steps involved in the delivery primary health care is an important focus of attention when considering the issues to be prioritised in the CQI action plan.” The NACCHO Secretariat has applied this “primary focus” to the Patient Journey through primary health care services and hospital care. Three Patient Journey Diagrams have been developed which Chief Executive Officers and senior managers of ACCHOs may like to consider using when they: (a)Prepare their PDSA Cycles for their CQI Action Plans; and (b)Review where they could possibly improve their systems, procedures, technologies or staff deployments If you want to ask any questions about the contents of this Table, please contact NACCHO’s Chief Information Officer, Dr Robert Starling, at [cio@naccho.org.au].

3. There are 3 Powerpoint Tools 1.The first Powerpoint Tool is an animated Powerpoint diagram of a generalised Patient Journey through an ACCHO’s primary health care system 2.The second Powerpoint Tool identifies the service interface for a Patient between the ACCHO and a visit to a Public Hospital 3.The third Powerpoint Tool identifies the steps in a typical Patient’s Hospital Stay

4. The diagrams bring together the main points and recommendations from a number of sources including: ACCHOs Model of Well-being and Care (1971 – on-going) COAG-CTG programmes (2010 – on-going) Productivity Commission NIRA Report (2015) AHMAC Aboriginal and Torres Strait Health Performance Framework (2015) National Aboriginal and Torres Strait Islander Health Plan and Implementation Plan (2015) National Aboriginal and Torres Strait Islander Continuous Quality Improvement Framework and Implementation (2015) Standard Funding Agreement (2015) reporting requirement, namely: –Online Service Report (OSR) and –national Key Performance Indicators (nKPI) National Health Performance Authority – MyHealthyCommunities (2015) Mapping the patient journey for CQI Action Plans

5. How to use the first Powerpoint Tool NACCHO has prepared an animated Powerpoint diagram (switch to “Slide Show” mode in Powerpoint to click through the animation) of a generalised Patient Journey including single and/or multiple morbidities, expressed as a timeline over a period of one year Most of the steps in this Patient Journey can be applied to other types of clients The diagram is divided into two halves: -The bottom half describes the ACCHO’s processes in this part of the Patient’s Journey -The top half identifies the specialist, pharmacy and allied health services that might typically be provided The relevant MBS service Items have been identified at each point of service along the Patient Journey ACCHO Practice Managers, CEO and Service Medical Officers could review your ACCHO’s service delivery processes and systems against this Patient Journey map as a guide to identify if and where Continuous Quality Improvements could be installed These improvements could then be documented in your CQI Action Plan If you want to discuss this map, please email Rob Starling, cio@naccho.org.au

6. Note: PIP consent only after chronic disease determi ned 15+ Health Check GP Mgmt Plan (CD/TI) Optom- etrist Cardiologist. Annual Review Team Care Plan Consent for SIEHCP Nephrologist Podiatrist Psychologist Psychiatrist Speech Pathologist Other PHC Provider e.g. Private GP, Super-Clinic Time Line Schematic of Patient Journey Primary Health Care GP+Pharma Medication Mgmt review Physiotherapist Aboriginal Community Controlled Health Services Provider Partners AICCHS Pharmacy (S100) MBS 715 Need to add PIP, MBS and EPC etc. Item numbers on arrows; In future can add to arrows:. Admin costs, current and with SIEHR/SIEHCP. Savings in tests/treatments;. Gap between activities on time line indicates waiting time.. Add location of providers and get distances to be travelled (access) (Quarterly, semi-annual, periodic reviews) e-Referral Review MBS 721 723 715 9-12mnths 732 – 3-6 months 2712 between 4 weeks to 6 months after initial MHTP GPMP/TCA Review 732, MHTP 2712 Case Conference items 735 - 758 10970 81360* 82005* 10960 81335* 10962 81340* GP Mental Health Care Plan, Review & Cons 2700,2701,2715,2715,2712, 2713 Group 80000- 80020 QAAMS Pathology Point of Care Testing Items 80100- 80170 & 81355, 10968 319+ Many item numbers New 73739 – Diabetes diagnosis 73840- HbA1c 73844 - ACR MBS 900 Antenatal Check MBS 16500 16590 Explanation of conditions and care options Model developed by Robert Starling and Amanda Hand (2009) updated by QAIHC/NACCHO 2015 Dashed arrows Red – referral, Purple - seen Green – report provided and patient electronic health record updated © NACCHO 2015

7. How to use the second Powerpoint Tool NACCHO has prepared a Powerpoint diagram of a generalised Patient Journey that involves a visit to a Public Hospital (switch to “Slide Show” mode in Powerpoint to click through the animation) The diagram illustrates how a period of time in hospital fits in with the longer term Patient Journey ACCHO Practice Managers, CEO and Service Medical Officers could review your ACCHO’s service delivery processes and systems against this Patient Journey map as a guide to identify if and where Continuous Quality Improvements could be installed between ACCHOs and Hospital Admissions and Discharge activities These improvements could then be documented in your CQI Action Plan If you want to discuss this map, please email Rob Starling, cio@naccho.org.au

8. Note: PIP consent only after chronic disease determine d 15+ Health Check GP Mgmt Plan (CD/TI) Annual Review Team Care Plan Consent for SIEHCP Aboriginal Community Controlled Health Services AICCHS Pharmacy (S100) MBS 715 Need to add PIP, MBS and EPC etc. Item numbers on arrows; In future can add to arrows:. Admin costs, current and with SIEHR/SIEHCP. Savings in tests/treatments;. Gap between activities on time line indicates waiting time.. Add location of providers and get distances to be travelled (access) e-Referral Review MBS 721 723 715 9-12mnths 732 – 3-6 months 2712 between 4 weeks to 6 months after initial MHTP Case Conference items 735 - 758 GP Mental Health Care Plan, Review & Cons 2700,2701,2715,2715,2712, 2713 Group 80000- 80020 Antenatal Check MBS 16500 16590 Explanation of conditions and care options Model developed by Robert Starling and Amanda Hand (2009) updated by QAIHC/NACCHO 2015 Hospital Visit - Hospital detailed records with Care Plan SIEHR/ SIEHCP/eReferral e-Discharge Optom- etrist. Speech Pathologist Other PHC Provider e.g. Private GP, Super-Clinic GP+Pharma Medication Mgmt review Provider Partners 10970 81360* 82005* QAAMS Pathology Point of Care Testing Items New 73739 – Diabetes diagnosis 73840- HbA1c 73844 - ACR MBS 900 Dashed arrows Red – referral, Purple - seen Green – report provided and patient electronic health record updated Schematic of Patient Journey Primary Health Care incl. a stay in hospital © NACCHO 2015

9. How to use the third Powerpoint Tool NACCHO has prepared a Powerpoint diagram of a generalised Patient Hospital Stay The diagram is divided into two halves: -The bottom half describes the Hospital processes in the Patient’s Journey -The top half identifies the specialist services that might typically be provided The diagram illustrates the importance of a Patient’s primary health data being available when there is an admission to hospital and the importance of detailed information about actions undertaken while in hospital to improve patient care when returning to their community ACCHO Practice Managers, CEO and Service Medical Officers could review your ACCHO’s service delivery processes and systems against this Patient Journey map as a guide to identify if and where Continuous Quality Improvements for Continuity of Care at admission and Discharge with the Hospital Sector could take place These improvements could then be documented in your CQI Action Plan If you want to discuss this map, please email Rob Starling, cio@naccho.org.au

10. Consent for access to SIEHR/ SIEHCP Diagnostic Imaging Optometrist Surgeon Cardiologist. Nephrologist Podiatrist Psychologist Psychiatrist Speech Pathologist Discharge Summary PHC Provider e.g Private GP, ACCHO, Super-Clinic Time Line Schematic of Patient Journey Hospital stay Physiotherapist Hospital/Acute Services Specialist Services Pathology Enter Here DMO/Specialist Primary Carer Care Plan/ Hospital Record Referrals Observations and Measurements Update SIEHR SIEHCP Consent documents including Informed Financial Consent statements Medical options summaries Model developed by Robert Starling and Amanda Hand (2009) updated by QAIHC/NACCHO 2015 © NACCHO 2015