Mid North Coast: Safe Transition Of Care

Dr Adrian Gilliland is a Coffs Harbour general practitioner, chair of NCPHN’s Mid North Coast (MNC) Clinical Council and board member of the MNC Division of General Practice. He has been a key GP involved in the development of the Safe Transition of Care Program on the NSW North Coast.

Dr Gilliland spoke with the joint LHD/PHN Project Manager, Isabel Butron, regarding regional NSW impacts on patients and providers.

Isabel: Dr Gilliland, patients outside of the urban centres often have to wait longer or travel more to see a GP or access emergency care. And when they do, they often assume their care-related information flows seamlessly back to their GP or hospital doctors. From your experience, what sorts of challenges surround care transfers and are there any specific issues in regional/rural settings?

Dr Gilliland: Busy GPs, ED doctors and health professionals often need to share electronic summaries that community-based GPs and nurses need to pick up and continue. In rural and remote Australia, where there are limited services and greater workforce pressures, it is even more important that GPs get timely messages regarding what happened to their patient in hospital or in ED and vice versa.

In this project we’ve seen many examples where transfer or discharge summaries were sent but not received, and where hospitals see the same patients return due to missed opportunities in the community. Both sectors often struggle to fix these issues alone. Not receiving the discharge summaries adds further time spent running around to get the information while we should be using this time focusing on our patient’s needs. Some of our patients need to travel a substantial distance to see us – the idea of not knowing that the patient has been in hospital is a very serious concern.

Isabel: So how did the project get clinical input regarding these challenges around shared electronic communications, and what kinds of areas did it focus on?

Dr Gilliland: Clinicians raised the issues and concerns in a number of forums. We heard that the timeliness and quality of the discharge summaries were inconsistent across the board. As a network group we just didn’t know how to go about trying to rectify the problem and what the actual barriers were. Therefore, in collaboration with the PHN and our local LHDs, we sought to identify these barriers and provide recommendations for improving the timeliness and quality of discharge summaries. We also did a survey that received unheard of response rates and we spoke with a range of leaders locally, regionally and in other settings, eg. eHealth.

Isabel: The Rural Health Alliance is a key body that can provide leadership in developing and prioritising critical communication enablers such as this. Given this project was designed to investigate and recommend broader more complex reforms, what are the key messages that rural and regional leaders can advocate on or influence wherever possible?

Dr Gilliland: We are still finalising our recommendations in partnership with NSW Ministry/eHealth, the MNCLHD and NCPHN, but it seems clear that the timeliness and quality of this kind of information is extremely critical for the safety and high standard of care our rural and regional patients and health professionals deserve. RHA is a strong advocate for getting high-quality medical services in place in regional and remote areas, however the actual work supporting these professionals to communicate effectively once established is sometimes overlooked. This is a vital message that RHA could advocate for.

Isabel: Dr Gilliland, as stated above, you have been instrumental in advocacy and support of this program across the North Coast. What do you think has been unique in this project and have you seen benefits from this project in your own practice?

Dr Gilliland: This project has undeniably had some big impacts to the North Coast. We have seen a stronger relationship formed between each of the hospitals and the PHN with hospitals. The relationship we now have across the major stakeholders has seen shared planning and shared solutions contribute to a better outcome.

The benefit realised to date within my own practice is that we have seen an increase in the timeliness of discharge summaries coming in. We now have a concise discharge notification from our Emergency Department. We have seen an increase in the receipt of Mental Health discharge summaries. Overall we are confident that we will see an increase of the timeliness of discharge summaries and an improvement in the quality.

Isabel: Finally Dr Gilliland, what is the message or statement you would like to say to our regional area?

Dr Gilliland: The Safe Transition of Care is a big piece of work and we have only begun. We are yet to implement further solutions and recommendations across with our LHD partners. Looking at the future we will need to focus on Primary Care changes and improvements.

We want to continuously improve to ensure our patient’s safety.

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A word from Dr Grant Rogers, Rural eMeds Chief Medical Officer/Clinical Lead, Rural eHealth Program:

“With the coming of eMeds implementation to 112 sites across the six rural LHDs, we hope this will contribute to the quality of discharge summaries and enhance the Transition of Care efforts to date. Integrating care between LHDs, PHNs and primary care (GPs and Community Health) services is vital in improving the patient’s journey. Every effort is being made to improve the flow of clinical information across the healthcare spectrum.”

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