1. Gold Coast Complex Care Project (MyHealth)
Welcome and explanation of who is who
Content:
Rationale for the project
Where it fits within the Gold Coast Population Health Project, research agenda
Overview of the project
Overview of roles of admin, nurse and doctor
Focus on examples from GP experience in multimorbidity of prevention, deprescribing, coding, using Care Plan for coordination, patient safety
Conclusion and reminder of key role as ‘credibility lead’
Presentation developed Dr Mark Morgan
Associate Professor Bond University, Eastbrooke Family Clinic, Gold Coast

2. Acknowledgements This presentation was developed by Dr Mark Morgan
Associate Professor Bond University, Eastbrooke Family Clinic, Gold Coast
MyHealth Collaborative team, Centre of Research Excellence
Mark Morgan, Chris Healey, Kevin Mc Namara, Kate Schlicht, Michael Coates
Gold Coast PHN team and Dr Evan Ackermann
Mudgeeraba General Practice, Harmony Health Medical Centre, Mermaid Central Medical Clinic, On The Park General Practice

3. Fred Too much medicine Reducing over-treatment de-prescribing de-specialising de-intervening

4. Over 75 Health Assessment
GP team
New GPMP/TCA
Review 1
Plus seasonal focus
Review 2
Review 3

5. GP Management Plan
My Story
My values
My goals
If my health deteriorates
Medical goals
Advanced Health Directive
My Health Summary & Measures

6. Seasonal Focus

7.
Search ‘Scotland’ ‘polypharmacy’

8. Research outcomes

9. Example – Tier 4 intervention Avoidable admissions for people aged 75+
4 practices, 4 different software packages
Through facilitated co-design process all 4 agreed on:
common template to support 75+ health check
common complex care plan template aligned to MBS items
Through our data platform:
177 high risk patients
400 moderate risk patients
recalls commenced
care plans being completed
new needs being addressed
Recruited 4 practices with 4 different common GP software packages
Practice support staff undertook co-design process, ensuring everything aligned to existing MBS item number requirements and agreed health care check and care plan templates.
Data which is deidentified before leaving the practice brought into the platform (the primary sense tool) to look at key data items already sitting in practice software data which may indicate patients at risk.
Indicated a total of 177 high risk patients, 400 moderate risk patients and this is fed back to practices. Once back in practice at risk patients can be reidentified, by the practice, and this can inform recall of the at risk patients.
Practices are currently recalling patients and at least 16 have occurred at one practice and indications are that it is likely the other practices will have similar numbers.
Early feedback from clinicians is this process is uncovering a range of previously unknown issues for patients including social issues, a major factor in avoidable admissions for this age group which they begin to intervene

10. Thank You Further information
and
Gold Coast PHN