Background – how did we get here? Joint Project between NNSWLHD & NCPHN to develop a whole of system strategy, to better respond to the healthcare demands over winter Initiatives were developed in partnership a series of workshops were held between February and May to design the program involved more than 51 stakeholders from LHD, PHN, General Practice, Ambulance, AMSs and Consumers.

Winter Strategy Aims Aim 1: Improve respiratory hygiene and vaccine uptake, slowing the seasonal epidemic of infectious respiratory conditions using a population wide campaign; Aim 2: Provide Assistance and support to General Practice to facilitate a planned and proactive management of very high risk patients in the community; Aim 3: Establish an efficient and effective process for transfer of care from hospital to community during winter.

Aim 2: Funding and Supports for General Practice Aimed to support general practices to keep their most vulnerable patients well and reduce their likelihood of being hospitalised over winter The program provided funding and resources to identify and support at risk patients. July 1st until 29th October 2017.

Practices well distributed Many had never worked with us previously

• 50% of registered patients are 71 years or older. • The oldest patient is 99 years and the youngest 26 years. • median age is 75 years and the overall average is 73 years. • 68% of patients have more than 5 medications. • Over 30 % of patients have Chronic Obstructive Pulmonary Disease, Ischemic Heart Disease or Diabetes and 22% have Asthma. • 22% of patients are living alone.

Sick Day Action plans- X nurses trained and supported by CDM team to adopt these Self Management- SDAPs and Coaching by PN or CDM nurse . We have identified the need for further investment in this area Regular monitoring by practices -

What we are learning….. General Practices can (and should) be harnessed to help prevent hospitalisations GPs were willing to participate know their patients and can identify those who will most benefit from programs such as this are all different and benefit from a tailored support package CDM teams have an important role to play and benefit from more integrated working relationships Enablers are important Communication (ADNs and Discharge Communication) Provision of tools (HealthPathways) Reporting and monitoring systems Evaluation still ongoing… General Practices were enthusiastic about participating General Practices know their patients and can identify those who will most benefit from programs such as this - General Practice software systems were harnessed to identify and flag a cohort of patients Each practice is different and would benefit from a tailored support package Practice nurse capacity Enablers such as IT and use of internet patchy PROMs and PREMS- not the great panacea to hearing the patient voice. They are designed as a tool to enhance patient care. Caution with using them as an evaluation tool as it may diminish enthusiasm and make collection an act of compliance. Enablers are important to overcome exisiting system barriers to working effectively together across the health system. Data from both LHD and GP systems can provide intelligence about what is happening with this patient cohort, but they are not well linked up. If we want data we need to make its collection easy to do, particularly in General Practices. Its important to make it easy so that the administrative burden is not overwhelming