1. Inner North West Chronic Disease & Service Coordination Workshop Chronic Disease & Service Coordination Progress Across Our PCP Catchment Presented by Emily Hooke September 14 th 2011

2. Inner North West PCP Significant Pockets of Disadvantage 3-7 % are public housing tenants (higher in Yarra with 11% public housing) High rates of unstable housing (129 per 10,000) Over 1200 Aboriginal & Torres Straight Islanders 34 – 48% speak a language other than English at home 20% have poor English language proficiency Source: Australian Bureau of Statistics, Socioeconomic Indexes for Areas (SEIFA), 2006.

3. Chronic Disease in the Inner North West Chronic Disease Prevalence Source: National Health Survey (NHS) 2007-08. Inner North West Estimate for 2009 ConditionPersons Arthritis60,062 Asthma43,083 Hypertension36,266 CHD & Stroke 20,979 Diabetes Type 213,258 Cancer6,011 Chronic Disease Prevalence Source: National Health Survey (NHS) 2007-08. Inner North West Estimate for 2009 ConditionPersons Arthritis60,062 Asthma43,083 Hypertension36,266 CHD & Stroke 20,979 Diabetes Type 213,258 Cancer6,011 Burden of Disease Source: Australia’s Health 2010, Health Across Life Stages www.aihw.gov.au/publications/aus/ah10/113 74-c06.pdf 15 – 24 years Mental Illness 25 – 39 years Mental Illness, specifically Anxiety & Depression 40 - 54 years Most people have at least one chronic health condition 55-64 years Chronic Disease represents the highest burden of disease Burden of Disease Source: Australia’s Health 2010, Health Across Life Stages www.aihw.gov.au/publications/aus/ah10/113 74-c06.pdf 15 – 24 years Mental Illness 25 – 39 years Mental Illness, specifically Anxiety & Depression 40 - 54 years Most people have at least one chronic health condition 55-64 years Chronic Disease represents the highest burden of disease Avoidable Hospital Admissions Source: VHISS, Ambulatory Care Sensitive Conditions 1 Diabetes 2. Cardiac Disease 3. Dental Conditions 4. Kidney Disease Avoidable Hospital Admissions Source: VHISS, Ambulatory Care Sensitive Conditions 1 Diabetes 2. Cardiac Disease 3. Dental Conditions 4. Kidney Disease

4. Inner North West PCP Vision To ensure that -healthcare is equitable, regardless of circumstance or disadvantage -the health service system is easily navigated -the best care is provided at the best place and time, including prevention, screening and early intervention Key Deliverable Areas: Partnerships Service Coordination Integrated Health Promotion Integrated Chronic Disease Management

5. Victorian Service Coordination Practice Standards Victorian Service Coordination Practice Manual 2009 Provides a vision for Victoria’s Service Coordination and Practice A Reference Guide Consumer Outcomes & Good Practice Indicators Consumer Pathways Tools & Resources Covers Initial Contact Initial Needs Identification Assessment Care Planning Referral Available online at : http://www.health.vic.gov.au/pcps/downloads/sc_pracmanual2.pdf

6. Victorian Service Coordination Practice Standards For Initial Needs Identification (INI).......

7. Victorian Service Coordination Practice Standards Good Practice Guide 2009 Provides Good Practice Guidelines for Initial Contact Initial Needs Identification Assessment Care Planning Referral Available online at http://www.health.vic.gov.au/pcps/downloads/good_practice.pdf

8. Victorian Service Coordination Practice Standards Continuous Improvement Framework 2009  Supports organisations to monitor and improve service coordination implementation and practice  Forms the basis for the state wide Service Coordination & ICDM Surveys  Based on PDSA (Plan, Do, Study, Act) cycles of improvement Available online http://www.health.vic.gov.au/pcps/downloads/continuous.pdf

9. Victorian Service Coordination Practice Standards Service Coordination Tool Templates 2009  Suite of templates  Supports Service Coordination Practice  Standardised format for collection and sharing of consumer information  Formalised documentation of consumer consent SCTT 2012 Revision Project Improvements based on working group feedback SCTT 2012 will be piloted prior to implementation Available online: http://www.health.vic.gov.au/pcps/downloads/sctt_user_guide09.pdf

10. Wagner Chronic Care Model

11. Service Coordination & ICDM Survey Annual Survey Supports review of Service Coordination & ICDM Practice & identifies areas for improvement Survey Questions mapped to the Accreditation Standards QIC Standard (6 th Edition)ACHS – EQuIP 5 Standard Agencies can benchmark against previous results Enables PCPs to deliver targeted partnership strategies 3 Levels of Results are reported: Agency PCP Catchment Victoria All PCP member agencies engaged in Service Coordination/ICDM are encouraged to participate Several minor changes to the 2011 Survey

12. Service Coordination & ICDM Survey The Surveys went live on 1 st September 2011 Information is available at: www.health.vic.gov.au/pcps/coordination/cqi.htm The Surveys will close on the 31 st of October 2011

13. 2010 Service Coordination & ICDM Survey Where we are doing well... Service Coordination principles and standards integrated into policies, position descriptions Service Coordination principles integrated into consumer feedback systems Provision of information to consumers in response to an enquiry Initial Needs Identification conducted within 7 days of Initial Contact Care Coordination Plans for clients with multiple and complex needs GP provided with copy of Care Plan (where one existed) Referral acknowledgements sent within 7 days of receipt of non- urgent referrals

14. 2010 Service Coordination & ICDM Survey Common areas for improvement..... Service Coordination template Tools (SCTT) in client referrals Timely review of care plans Referral acknowledgements sent within 2 days of receipt of urgent referrals Evidence that consent form has been completed for all relevant referrals Documentation of Assessment meets Victorian Service Coordination Practice Standards Intra-agency care plans meet VHA criteria Feedback to GPs has been documented Clinical care protocol/pathways/decision support tools demonstrate delivery of best practice and continuity of care Documentation of self management support including health behaviour change A formalised quality improvement system for ICDM is in place

15. 2010 Service Coordination Survey Results Part A: Service Coordination

26. Part B: ICDM

27. 2010 Service Coordination Survey Results Part B: ICDM

34. Much work is already underway...

35. Resources to Support This Work Checklist: Monitoring Organisational Chronic Disease Management Quality Initiatives www.health.vic.gov.au/pch/downloads/icdm_checklist.doc ICDM Status Report (2010) http://docs.health.vic.gov.au/docs/doc/Status-Report-2008-10 ADMA Clearing House http://clearinghouse.adma.org.au/ PDSA Improvement Methodology http://www.health.vic.gov.au/pch/gpp/pdsa_overview.htm

36. Tools That Assess Organisational Systems Assessment of Chronic Illness Care (ACIC) MacColl Institute for Healthcare Innovation (USA) www.improvingchroniccare.org/index.php?p=ACIC_survey&s=35 The Audit & Best Practice for Chronic Disease: Systems Assessment Tool (ABCD ‑ SAT)––Menzies School of Health Research (NT, Australia) www.health.vic.gov.au/pch/downloads/app11_systems_assess_tool.doc Organisational Skills Analysis Tool: Chronic Disease Care Gill and Willcox (Vic, Australia) www.gillandwillcox.com.au

37. Tools That Assess Consumer Experience of Chronic Disease Care Patient Assessment of Chronic Illness Care (PACIC) MacColl Institute for Healthcare Innovation (USA) www.improvingchroniccare.org/index.php?p=PACIC_Survey&s=36

38. Tools that Assess Specific Components of Chronic Disease Care Self-Management Assessment Tool for Community Health Organisations Gill and Willcox (Vic, Australia) www.gillandwillcox.com.au Service Coordination & ICDM Survey Department of Health (Vic, Australia) www.health.vic.gov.au/pcps/coordination/cqi.htm