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Mar
29
2018
PHNs have been established with the key objectives of increasing the efficiency and effectiveness of medical services for patients, particularly those at risk of poor health outcomes, and improving coordination of care to ensure patients receive the right care in the right place at the right time.
This is our job. It’s a big one. One way we strive to meet this lofty charter is to foster quality improvement at a patient, practitioner, practice and population level.
At the heart of this is the mobilisation of data to inform change and build practice teams. And, by change, we mean ‘meaningful’ change!
While data is all around us – in patient surveys, clinical and team meetings, national registers or feedback posted on your Facebook page – the NCPHN Measuring for Improvement (MI) Program, using the PenCAT suite of tools, provides structure and a great place to start that will motivate your whole practice team.
We currently have 116 practices on the QI continuum all working at their own pace – one of the highest engagement rates in the country – and we think that speaks volumes about the passion of North and Mid North Coast practices.
Practices working on QI now, and making it business as usual, will be well placed to meet and exceed requirements for 5th Standards Accreditation and the QIPIP when it is rolled out in 2019.
NCPHN provides free user licences for Cat4 and Topbar. Practice teams can access training, templates and tools that guide you through all things QI. You will have access to a wide network of information, free facilitated Patient Centred Medical Home workshops to kick start QI as a team sport, collaboration opportunities, dashboards that look great on your tea room noticeboard and provide a perfect jumping off point for targeted work, a QI portal for you to store and manage your improvement ideas and topic based guides to provide the structure that is key to quality improvement.
Currently we have topic guides on Data Quality, Digital Health, Diabetes and Asthma available to assist your quality improvement work. We are developing guides for COPD, Women’s Cancer Screening and Aboriginal Health.
Practices start small and are encouraged to work together on achievable initiatives. We support documentation of Plan Do Study Act (PDSAs) cycles which are simply Quality Improvement efforts documented (always a challenge in busy work environments) and measured using a consistent methodology.
Practices on the North and Mid North Coast are working on a range of PDSA cycles around building a team, completing cycles of care, improving and maintaining data quality, improving consistency of coding, addressing screening or immunisation rates. You name it, someone is doing it.
We’re passionate about the health of our community. We know that you are, too. If you want assistance, want to know more, or want to give us feedback on what we are doing we want to hear from you.
Discharge Summary Update from the Northern NSW Local Health District
Online Referrals to Quitline Now Available
Healthy North Coast acknowledges the Traditional Custodians of the lands across our region, and pay our respect to Elders past, present and on their journey. We recognise these lands were never ceded and acknowledge the continuation of culture and connection to the land, sky and sea. We acknowledge Aboriginal and Torres Strait Islander peoples as the Land’s First Peoples and honour the rich diversity of the oldest living cultures.
We acknowledge the traditional custodians of the land we live and work, the Bundjalung, Arakwal, Yaegl, Gumbaynggirr, Githabul, Dunghutti and Birpai Nations, and their continuing connection to land, sea and community. We pay our respects to elders past, present and future.
Strategic Priority Area: One team
North Coast is identified as the region most likely to be impacted by climate change in Australia and also forecasted greatest growth in those 65+.
Healthy North Coast takes a lead role in ensuring the older population and the sector that supports them are prepared for, can respond to and recover from disasters and other emergencies.
We have led eight regional disaster management capacity building workshops, bringing together SES, community organisations and the aged care sector.
We have also developed disaster preparedness tip sheets for both residential and community aged care providers.
Strategic Priority Area: One team
In May 2022, the NSW Parliament passed the Voluntary Assisted Dying Act 2022. Effective from Tuesday, 28 November 2023, eligible people have the choice to access voluntary assisted dying.
Healthy North Coast has developed a webpage for both health professionals and consumers, with links to available information and resources.
Strategic Priority Area: No one is left behind
Healthy North Coast has worked with people living with dementia, their families and local service providers to develop an information booklet that will help them connect with local and national supports along their journey.
Highly regarded by a range of professional supporting those on or starting the dementia journey, the booklet includes commonly asked questions for people to ask their GP and/or specialist.
“It’s a fantastic resource and I give it to everyone on their first diagnosis. Its easy to read, so well planned and thought through and has lots of really useful information, tailored to the region.
I also find it very helpful when educating clinical staff.”
−Geropsychiatric Nurse Practitioner, Mid North Coast.
The resource is available in digital and printed copies, with more than 5,000 distributed across the region. An e-version is available to clinicians via the Dementia and Cognitive Impairment HealthPathway.
Strategic Priority Area: One team
The Deteriorating Resident Response Tool (DRRT) has been developed to guide RN’s in Residential Aged Care homes (RACHs) to better understand, anticipate and make clinical decisions responding to the deteriorating health of residents.
The objective of the DRRT is to give RACH staff clear information to triage and provide appropriate care for a range of residents’ health conditions, and, in turn, prevent unnecessary presentations to ED.
The tool has been designed together with a specialist geriatrician, consulting with stakeholders such as Residential Aged Care Managers, NSW Ambulance, GPs, and experts from Mid and North Coast LHDs.
The pilot commences in March with four participating RACHs. Evaluation measures will include effectiveness in building RN confidence and reported reduction in unnecessary hospitalisations. Findings will inform a future planned, region-wide implementation.
Strategic Priority Area: No one is left behind
The Care Finders program is a free region-wide service to support vulnerable older people who have no-one else to help them, to learn about, apply for and set up support services.
Care finders can help people understand what aged care services are available, set up an assessment, and find and choose services. They also help people with access to other supports in the community, both accessing services for the first time and changing or finding new services and supports.
On the North Coast, Healthy North Coast has commissioned four organisations to provide this important service: EACH, Carexcell, Lifetime Connect and Footprints.
Strategic Priority Area: Improving Lives Now
Healthy North Coast commissions two service providers to deliver psychological therapies and supports for older people with, or at risk of developing, a mental illness and who are living in residential aged care homes (RACHs).
The aim of the program is to both provide direct support to residents and their families and carers, as well as upskill the RACH workforce to respond to the needs of residents presenting with mental health concerns.
Strategic Priority Area: Securing a Healthier Future
Delivered by Feros Care, the Healthy Me, Healthy Community program aims to build individual and community connections to reduce loneliness and improve wellbeing in Port Macquarie.
The program helps people to connect with community, activities, supports and services that address their broader social determinants of health, as an alternative or supplement to a clinical approach.
Strategic Priority Area: Improving Lives Now
The Royal Commission into Aged Care Quality and Safety identified several critical areas affecting aged care residents and our health system. Key challenges include:
Telehealth offers valuable opportunities to enhance support for residents living in aged care homes. Funded by the Commonwealth Department of Health and Aged Care, this initiative provides telehealth equipment and staff training as part of the response to the Royal Commission’s findings.
By improving access to primary care clinicians, specialist services, and other service providers through telehealth, we can significantly enhance health outcomes for residents, reducing unnecessary hospital transfers and emergency department visits.
The selection of telehealth equipment was guided by our Healthy Ageing Strategy (HAS), a comprehensive digital discovery questionnaire, and consultation workshops with various stakeholders. These efforts included interviews with residents to understand their attitudes toward telehealth, ensuring the initiative meets their needs and preferences.
Strategic Priority Area: Improving Lives Now
Aims to provide people who have life limiting conditions the opportunity to exercise choice and receive high quality care at home, harnessing improved and better coordinated supports and services that meet their individual needs.
Program objectives:
These objectives will contribute to achieving the following intended overarching outcomes of:
Funding is open to all primary care providers within disaster affected communities across the Healthy North Coast footprint.
Workforce Locum support and R&R funding criteria
Wellbeing Flexible Funding Criteria & Eligibility
| *Team Size (Total staff and contractors) | Funding Available |
| Small (1-5) | $500-$1500 |
| Medium (6-20) | $1500-$4000 |
| Large (>20) | $4000-$5000 |
