May

05

2021

Reported benefits for the MNC Admission and Discharge Notification Pilot

This update has been provided by Mid North Coast Local Health District.

The Mid North Coast Admission Discharge Notification (ADN) pilot is completing the evaluation phase of the project. If you haven’t already, share your feedback today.

To date, around 102,000 ADNs have been successfully delivered to general practitioners.

The benefits of receiving these notifications are being reported in a number of ways. Through the ADN pilot evaluation feedback, Aboriginal Medical Services (AMS) have said they are now able:

  • Recall high risk patients for health management and safe transition of care
  • This primary care recall has reduced the re-presentation in hospital
  • Make appointment immediately for patients if necessary
  • Monitor Discharge Summary received 

1. High-risk patients identified through hospital ADNs

In January this year, Werin Aboriginal Corporation Medical Centre received 123 notifications. 

Staff were able to identify 13 high-risk patients that were recalled back to the practice. Management of these patients through primary care has been successful, with only two recalled patients re-presenting in hospital.

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2. Monitoring of a patient’s journey through hospital and practice

Another identified benefit has been through the monitoring of a patient’s journey through hospital and practice. 

The story below indicates the number of presentations of a single patient. 

By transitioning care, it has been evidenced that the patient did not represent for February and March of 2021. 

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Click to enlarge

Dr Ryan Partridge has shared this story of the patient’s journey below:

Mr. X. is a young Aboriginal patient of mine at Bowraville GP with a long history of pancreatitis secondary to alcohol abuse. He had many presentations to Macksville ED with subsequent transfer to CHHC for acute abdominal pain secondary to his condition. The number of ED presentations between the 2018-2021 periods was well over 20. He was under the care of a General Surgeon and had appropriately been referred to the CHHC Pain Service. One of his admissions to CHHC was quite prolonged and required ICU admission.

As a result of these frequent presentations and subsequent admissions the CHHC/MDH ED Team and I developed a management plan for others to follow for future presentations. If the only issue at the time of presentation was uncomplicated abdominal pain then treatment with pain relief while in ED was the course of action. However for any pain complicated by examination findings or investigations then further discussion with the General Surgical team would be pursued. This plan essentially ceased the reflexive course of action for transferring him to CHHC.

Late last year (2020) we began receiving admission notifications via NSW Health for ED presentations. During this time it was noted Mr X. was still presenting to MDH ED however he was treated for presumed uncomplicated abdominal pain and discharged back to community. He had also been referred for dietary support and is currently under the additional care of the CHHC Chronic Pain Team.

Essentially we were able to see from these admission notifications that the plan we had put in place for his management was working. This enabled us to maintain our focus on his chronic needs with the assistance of our local Aboriginal Health Worker.

Please click here to provide us with more feedback about the ADN pilot.

The pilot evaluation will be closing soon. Share your thoughts about ADNs today to help make the case for their continuation or provide feedback otherwise.

Please contact the Mid North Coast LHD if you have any questions.

Aged Care Disaster Management Planning

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.

Voluntary Assisted Dying

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.

Living with Dementia 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.

The booklet includes commonly asked questions for people to ask their GP and/or specialist.

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.

Deteriorating Resident Triage Tool Pilot

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.

North Coast Care Finders Program

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.

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Psychological services in residential aged care homes

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.

Social prescribing (Healthy Me Healthy Community)

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.

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Digital Health in Residential Aged Care

Strategic Priority Area: Improving Lives Now

Timely access to primary health care professionals, whether through face-to-face consultation or telehealth, is recognised as an issue for many Residential Aged Care Homes (RACHs), that in some cases can lead to potentially preventable hospitalisations. RACHs require adequate telehealth facilities to support access to virtual consultations for their residents.

Project goals

  • Assist participating RACHs to have appropriate telehealth facilities and equipment to enable their residents to virtually consult when needed with their primary health care professionals, specialists and other clinicians. 
  • Provide training to participating RACH staff to support them to have the capabilities to assist their residents in accessing virtual consultation services.
  • Encourage increased use of My Health Record by RACHs, to improve the availability and secure transfer of resident’s health care information between RACHs, primary care and acute care settings.
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Greater Choice at Home Palliative Care Program

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:

  • Improve access to palliative care at home and support end-of-life care systems and services (in primary health care and community care)
  • To enable the right care at the right time and in the right place (to reduce unnecessary hospitalisation)
  • Generate and use data to support continuous improvement of services across sectors
  • Use available technologies to support flexible and responsive palliative care at home, including in the after-hours.

These objectives will contribute to achieving the following intended overarching outcomes of:

  • Improved capacity and responsiveness of services to meet local needs and priorities
  • Improved patient access to quality palliative care services in the home
  • Improved coordination of care for patients across health care providers and integration of palliative care services in their region.

Education & training funding elibility

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

  • Available to primary care services in disaster impacted communities within the Healthy North Coast footprint.
  • Available to support short-term workforce coverage, allowing clinicians to rest and recover.
  • Workforce-support funding in total is capped for each site, over a 12-month period:
    • $10k for GPs and/or
    • $5K for nursing and/or
    • $5k administration support and/or
    • $5K allied/pharmacy and other.
  • Funding is not to be used to fill gaps in staffing that have not been able to recruit to and not to replace existing staff.
  • Healthy North Coast will assess requirements and approve available funding directly with the service requesting support.
  • Priority will be given to sites that have immediate, short-term workforce support needs.
  • Requests will be reviewed and supported on a case-by-case basis.
  • Program funding administered via RCTI Agreement (Recipient Created Tax Invoice) to be paid monthly, or on completion of the placement (whichever comes first).
  • Practices will be required to complete a request for payment form monthly, or on completion of the placement (whichever occurs first).

Wellbeing Flexible Funding Criteria & Eligibility

  • Open to all primary care providers within disaster affected communities across the Healthy North Coast footprint.
  • Activity must be purposeful, with the aim of increasing the wellbeing of your team.
  • Requests will be assessed on a case-by-case basis, with funding allocated based on team size.*
  • Following approval by Healthy North Coast, funding will be administered via RCTI Agreement (Recipient Created Tax Invoice) upon providing proof of expenses.
  • Funding cannot be used for the purchase of alcohol, or any other goods or services where the vendor cannot quote their Australian Business Number.
  • Planned activities must occur prior to 30th June 2024.
  • Funding will not be available for retrospective activities.
*Team Size
(Total staff and contractors)
Funding Available
Small (1-5)$500-$1500
Medium (6-20)$1500-$4000
Large (>20)$4000-$5000