“Improving whole of health outcomes for adults with severe mental illness in Lismore” A partnership project (2018-2019) 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

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 15-20 years earlier than the general population due to preventable conditions such as cardiovascular and respiratory disease

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

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.

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

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

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