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

2. 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

3. 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

4. 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

5. 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.

6. 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’

7. 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