1. “Improving whole of health outcomes for adults with severe mental illness in Lismore”
A partnership project ( ) between people with a lived experience of severe mental ilness, the Northern NSW LHD, the North Coast Primary Health Network, general practices, pharmacists and social care organisations in the Lismore local government area.
- Alison Renwick, Operational Support Mental Health, Northern NSW Local Health District
- Monika Wheeler, Acting Director – Integration (NNSW), North Coast Primary Health Network
- Sandra O’Brien, Integrated Care Coordinator - Mental Health and Drug & Alcohol, Northern NSW Local Health District
Slide 1: Title Slide with the 'name' of the project, location, organisational partners involved, names and roles of attending delegates
Slide 2: The Key Issue that the Integrated Care Program is seeking to address (i.e. the problem statement) (For Who and Why?)
Slide 3: The Core Aims and Objectives of the Integrated Care Project / Program (What?)
Slide 4: The Proposed Approach / Options Being Considered for the Implementation of the Integrated Care Project (How?)
Slide 5: Key issues the delegates wish to learn more about during their summer school experience

2. Rationale for change
Mental health issues were rated by Lismore community members as their top health concern in 2016
Northern NSW has the highest rate of suicide and highest rate for intentional self-harm hospitalisations
General consensus between stakeholders of fragmentation between services and high number of reform initiatives occurring in silos
People living with severe mental illness die years earlier than the general population due to preventable conditions such as cardiovascular and respiratory disease

3. Aims and objectives
To improve whole of health outcomes for adults with chronic and severe mental health in Lismore.
Patient Experience: People report that they feel in control of their health care goals and are supported by their health care team
2. Population Health: People‘s physical and mental health outcomes improve
3. Cost Effectiveness: Care is financiallay sustainable and delivered efficiently
4. Clinician Experience: Professionals experience a team based approach to quality care

4. Diagnosis results
Why? People are asked retell their story time and time again.
Why? Because patients experience of mental health services is not addressing their needs and wishes.
Why? Because current systems are provider centric.
Why? Because current funding and organisational structures do not support person care.

5. Analysis & design results
Input
Workforce (Executive, senior managers, project officers and collaborating partners)
Clinician time
Funding (>$110,000)
Information technology
Activities
Service development
Consultation
Governance – steering group, MOU
Provision of care
Training and education
Evaluation
Outputs
Trained professionals
New care models
FACT model
Joint case conferencing
Share care partnerships
Mental health nurses/peer support workers
Outcomes
People report that they feel in control of their health care goals
Majority of care provided by GP and episodic acute admissions reduced
Physical and mental health outcomes improved
PREMS/CREMS/PROMS

6. Bringing together partners, striving for optimal health and wellbeing
Mission statement
Bringing together partners, striving for optimal health and wellbeing

7. Action plan with timescales
Phase
Deliverable
2018
2019 J F M A S O N D
Initiation
Identify the project brief, key stakeholders and key personnel. Convene workshop with key stakeholders to discuss concept  
Diagnostic
Undertake research, literature review and collate baseline data, develop detailed project plan including scope and model, develop relationships with stakeholders and confirm Executive buy-in
Solution Design
Convene Steering Committee, convene co-design workshop to test and amend the scope and model of project, develop documentation, guides and processes to facilitate implementation of solutions in general practice, pharmacy, community health, acute health, social care organisations, conduct pre survey of all patients, carers, clinicians and others involved in project
Implementation
Implement change ideas as per co-designed model of care
Evaluation
Conduct patient, carer, clinician and other stakeholder post interviews, write final report including performance against performance measures and future recommendations