Navigating the Healthcare Neighbourhood Active trial site – Hornsby / Ku-Ring-Gai (Northern Sydney) Navigating the Healthcare Neighbourhood ACI partnering with Local Health Districts and Primary Health Networks IFIC Summer School – 29th March 2018 Regina Osten | Program Manager | NSW Agency for Clinical Innovation Rhiannon Beck | Senior Project Officer | NSW Agency for Clinical Innovation

Coordination and Communication Rationale for Change Health providers are funded differently, so systems aren’t aligned with one another Referrals are received that do not contain the required information Coordination and Communication Test results are not communicated across services, resulting in retesting GPs are unsure where to refer patients or seek clinical advice Patients are needing to repeat their health ‘story’ multiple times to multiple services Discharge summaries are not received in good time Needs assessment to identify particular areas of need for focus

“Stronger relationships, seamless integration, superior experience” Aims and objectives “Stronger relationships, seamless integration, superior experience” Local integration through a network of providers Enable stronger working relationships between neighbours Increase amount and/or quality of communication between neighbours Change attitudes towards other services Increase awareness of referral pathways Create opportunities for bottom-up innovation and integration (based on the principles of ‘Good Neighbours’) Principles for good neighbours Support your neighbours Be accessible Provide team-based care Define clear roles Enable and empower patients Ensure continuity of care Share responsibility for quality and safety Link to the community

Diagnosis Results Critical Issues: Key actions: There are benefits for all stakeholders to be involved, however we need to communicate the benefits for individuals frames of reference Prioritisation and/or improvement ideas may be difficult to reach consensus on with a ‘general’ invite list. People are skilled in collaboration and will quickly form good working relationships Consumers engaged in the process are supported and respected Key actions: Incorporate collaborative capacity training into sessions Review prioritisation process, consider using needs assessment to identify broad focus areas prior to workshop. Communications to be considered from different frames of reference Consumer-test language being used for workshops

Healthcare Neighbourhood Capability Strategy Assumptions Willingness of PHN and LHD to participate Good working relationship between LHD, PHN and ACI Neighbours will be interested in joining a neighbourhood and intrinsic motivation is sufficient to be involved The context of the work is favourable, and will remain favourable throughout the program Existing integration technologies and programs exist that can be leveraged Participants from general practice will see value and a future in the PCMH model Data sharing is supported Improved outcomes Improved efficiency Improved clinician experience Improved patient experience Stronger relationships, seamless integration, superior experience Broader Goals Audience - ACI Neighbours = Health providers, social care providers, consumers and carers End of Program Outcomes Neighbours willing to participate in the collaborative Improved partnerships between neighbours Neighbours see the benefits for themselves, patients, their organisation and the health system for working across providers Neighbours are more knowledgeable about PCMH, HCH and HCN Timelines: Immediate – date of first education session Intermediate – date of last education session End of program – 6 months from date of last education Activities are what translates the foundational activities into outcomes Neighbours improve their awareness of local services Neighbours discuss dependencies, opportunities and barriers Intermediate outcomes Neighbours reflect on the work of neighbours from other neighbourhoods Neighbours compile a stakeholder and enabler map Neighbours identify shared philosophies on providing care Discussion occurs between neighbours on online forum Neighbours form personal relationships with other local neighbours Neighbours reflect on what matters to them in their practice and compare to neighbours Immediate outcomes Neighbours from at least 4 different organisations attend knowledge program Neighbours use resources available on the website as required Other considerations: Sustainability / spread Engagement / incentives Activities ACI/LHD/PHN co-host knowledge program ACI promote the model at conferences , via social media, etc. ACI develop content for the website ACI record events and podcasts Audience for this Program Logic - ACI Additional foundational activities: Readiness assessment ACI write Guidebook for Healthcare Neighbourhoods ACI promote the Healthcare Neighbourhoods model ACI / LHD / PHN co-host events and podcasts with experts ACI build supporting web-based infrastructure ACI/PHN/LHD compile a needs assessment Foundational Activities ACI / PHN / LHD develop localised knowledge program curriculum ACI / LHD / PHN to identify local neighbourhood sites ACI / PHN / LHD trial sites sign Memorandum of Understanding Neighbourhood Steering Group approve capability strategy ACI form Healthcare Neighbourhood Steering Group

Healthcare Neighbourhood Collaborative Assumptions Willingness of PHN and LHD to participate Good working relationship between LHD, PHN and ACI Neighbours will be interested in joining a neighbourhood and intrinsic motivation is sufficient to be involved The context of the work is favourable, and will remain favourable throughout the program Existing integration technologies and programs exist that can be leveraged Participants from general practice will see value and a future in the PCMH model Data sharing is supported Improved outcomes Improved efficiency Improved clinician experience Improved patient experience Stronger relationships, seamless integration, superior experience Broader Goals Neighbours = Health providers, social care providers, consumers and carers Increase communication between neighbours Improve care coordination for patients End of Program Outcomes Neighbours Increase awareness of referral pathways Stronger working relationships between neighbours Neighbours Increase their use of eHealth technology Patients experience a more connected health system Neighbourhoods self-identify improvement cycles to complete Intermediate outcomes Neighbours negotiate and sign care compacts Neighbours are enthusiastic to implement small scale change and monitor the results Audience for this Program Logic: ACI, LHD, PHN Neighbours establish clarity on roles of responsibilities of neighbouring organisations Neighbourhoods confirm the shared vision for their local Healthcare Neighbourhood Neighbours undertake training in inter-professional competencies Immediate outcomes Neighbours from at least 4 different organisations meet one another and form informal relationships Neighbours from at least 4 different organisations learn about one another's professional roles Neighbours have defined improvement ideas Other considerations: Sustainability / spread Engagement / incentives Red halos indicate that the outcome is dependant on the improvements identified by neighbours Activities Neighbours attend collaborative sessions Neighbours prioritise areas for integration action Foundational Activities ACI develop Guidebook for Healthcare Neighbourhoods ACI establish template care compacts Neighbours submit EOI to join collaborative ACI / LHD / PHN to promote collaborative EOI process Neighbours attend capability building sessions Neighbourhoods develop a shared vision for their local Healthcare Neighbourhood Local priorities, stakeholders, enablers and readiness established

To be determined by the neighbours, including; Consumers / Carers Mission Statement To be determined by the neighbours, including; Consumers / Carers Health care providers Social care providers Service managers

Monitoring and Evaluation Action Plan with Timescales Monitoring and Evaluation 1 month: Review of needs assessment to select patient cohort/s 6 months: Workshop development and delivery - Workshop 1 – Introduction, relationships, visioning - Workshop 2 – Enablers, barriers and opportunities - Additional workshops (TBD) – networking, relevant local services, relevant evidence base for care 12 months: Innovation collaborative - Collaborative capacity building (inter-professional competencies) - Assessment and design - Improvement cycles