Activity Work Plan 2018-2019: Core Funding General Practice Support Funding After Hours Funding
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Activity Work Plan 2018-2019:
Core Funding
General Practice Support Funding
After Hours Funding
North Western Melbourne PHN
1
Activity Work Plan 2018-2019 (Core Funding, General Practice Support Funding, After Hours Funding) V1 –
16 April 2018 (D18-634620)Overview
The key objectives of North Western Melbourne Primary Health Network (PHN) are:
• 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 Activity Work Plan covers the period from 1 July 2018 to 30 June 2019.
1. (a) Strategic Vision for PHN
See link: https://nwmphn.org.au/wp-content/uploads/2017/08/NWMPHN_Strategic-Overview-Poster_FINAL-2pp.pdf
2
Activity Work Plan 2018-2019 (Core Funding, General Practice Support Funding, After Hours Funding) V1 –
16 April 2018 (D18-634620)1. (b) Planned PHN activities
– Core Flexible Funding Stream 2018-19
Proposed Activities
Improve the physical, mental and emotional health and wellbeing of children and families, with early
Activity Title / Reference (eg. CF 1)
intervention primary care approaches (CF 1)
Existing, Modified, or New Activity Modified: NP 4.3, NP 4.5, 4.6
Select one of the following: Population Health
Program Key Priority Area
Needs Assessment Priority Area (eg. 1, 2, 3) NWMPHN Health Needs Assessment November 2017: Section 4, Priority Area 2, pages 71-72.
This activity aims to improve health outcomes in childhood and within the family setting to promote
positive future health outcomes. This includes a strong parental/carer focus to ensure healthy
behaviours are modelled for children, including supporting the key institutions that children and
Aim of Activity families access.
The activity also aims to promote primary care options for paediatric health, to reduce potentially
preventable hospital presentations and admissions.
To support children and families receive safe, high quality, integrated and person-centred care in their
community, NWMPHN will commission for outcomes to:
• Promote protective health behaviours in children. This will include the physical and mental
health of children and a focus on immunisation rates. For example, commissioning of family
Description of Activity worker services to respond to the health and social needs of families with young children,
and young people between the ages of 12-25 years.
• Improve community and primary care provider confidence and capacity in working with
children, young people and their families/carers, through expansion of a specialist outreach
model in general practice to reduce potentially preventable hospital presentations and
admissions.
3
Activity Work Plan 2018-2019 (Core Funding, General Practice Support Funding, After Hours Funding) V1 – 16 April 2018 (D18-634620)• Support early identification of developmental delays and improve integration of services that
target early childhood development with primary health care and other relevant services. For
example, re-commissioning the ASPIRE Pilot Project in collaboration with Hume City Council
and Good Samaritan Primary School increasing access to allied health services to facilitate
early assessment, identification and referral to paediatricians and general practice for
developmental delay.
• Support primary care and communities to identify and respond appropriately to family
violence with a focus on priority locations within the region.
Following changes to the PHN schedules and guidelines, scoping work is being undertaken to further
inform the development of service and outcome specifications within the above identified focus
areas. This will include available data (including monitoring and evaluation of currently funded
services), contemporary Victorian and National policy and identified service and system barriers
informed by a broad range of stakeholders, including consumers. Services will be commissioned in
first and second quarters of 2018-19.
In addition, the approaches or mechanisms, i.e. enablers, that may be used to implement this activity
include: care navigation and access, quality improvement, health literacy, workforce development,
care pathways and e-health. After hours initiatives will also be considered, as appropriate.
• Children and families
• Priority populations most at risk of poor health outcomes eg children who are
Target population cohort developmentally vulnerable across five key domains
• Identified geographical areas of disadvantage or regional growth, such as Melton, Wyndham
and Hume
NWMPHN utilises a range of mechanisms to facilitate consultation, including through the Community
Advisory and Clinical Councils. Specific consultation and advice will be sought from a range of
relevant strategic and local organisations and stakeholders, such as peak and professional bodies,
State Government and emergency and acute services. Existing NWMPHN Expert Advisory Groups
Consultation - HSI Component may also contribute to this work eg Mental Health. In addition, ongoing consultation with new and
existing networks will ensure a coordinated approach to planning for priority populations and
targeted regions of vulnerability.
Consumers and people with lived experience are core to the work we do. Therefore, significant
consultation activities will be undertaken to ensure that a full range of relevant stakeholders
4
Activity Work Plan 2018-2019 (Core Funding, General Practice Support Funding, After Hours Funding) V1 – 16 April 2018 (D18-634620)including community members, community-based organisations, primary care providers, health
services, local government and community health have genuine input in the design and development
of interventions that may be generated.
Collaboration with key stakeholders will occur throughout the commissioning process. Consequently,
the following stakeholders may be involved in prioritisation, planning, implementation, monitoring and
evaluation of activities:
• NWMPHN regional and strategic partnerships and collaboratives (eg BHP4W and Shared Vision
for the North)
• General Practice
• Aboriginal Community Controlled Organisations
• Local Hospital Networks
• Community Health Services
Collaboration - HSI Component
• Local Government Maternal Child Health Services
• Child First and Family Services
• Primary Care Partnerships
• Allied Health
• Community based organisations
• Research institutes
• Peak and professional bodies
• Victorian Department of Health and Human Services
• Other identified providers
Population Health, Procurement, Planning and Evaluation, General Practice and other primary care
HSI Component – Other
support, Care Pathways (including HealthPathways).
Indigenous Specific NO
1 July 2018 – 30 June 2019.
Duration Planning for this activity is occurring currently. Procurement and commencement of delivery will
likely occur from the second quarter of 2018-19.
5
Activity Work Plan 2018-2019 (Core Funding, General Practice Support Funding, After Hours Funding) V1 – 16 April 2018 (D18-634620)Coverage NWMPHN region, and with a targeted focus on areas of growth such as Melton, Wyndham and Hume
All of NWMPHN’s activity aligns with the NWMPHN Commissioning Framework. Externally and
internally delivered services follow the three-stage cycle of: developing insight; plan and deliver, and;
evaluate and improve. The iteration that occurs within each stage ensures engagement,
responsiveness to local need and continual improvement. Within this activity, the different
Commissioning method (if known) components that form the activity, are at various stages in the cycle.
NWMPHN’s approach to market will be tailored to align with the local procurement context. An
approach to market may include expression of interest (EOI), request for tender (RFT) or direct
negotiation.
Decommissioning Not applicable
Proposed Activities
Activity Title / Reference (eg. CF 1) Improve the physical and mental health and wellbeing of people with chronic conditions (CF 2)
Existing, Modified, or New Activity New
Select one of the following: Population Health
Program Key Priority Area
Needs Assessment Priority Area (eg. 1, 2, 3) NWMPHN Health Needs Assessment November 2017: Section 4, Priority Area 1, pages 70-71.
The aim of this activity is to improve the physical and mental health and wellbeing of people with
Aim of Activity chronic conditions in the NWMPHN community, particularly priority populations most at risk of poor
health outcomes.
NWMPHN will commission services to deliver the following outcomes:
• Improved identification, assessment and management of the physical and mental health
Description of Activity needs of people living with chronic conditions.
• Improved self-management for patients with chronic conditions.
• Improved medication adherence for people living with chronic conditions.
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Activity Work Plan 2018-2019 (Core Funding, General Practice Support Funding, After Hours Funding) V1 – 16 April 2018 (D18-634620)• Improved integration of care to reduce unplanned hospital presentations or admissions of
people living with chronic conditions.
A co-design process with consumers commenced in 2017-18 that will inform the development of
service and outcome specifications for commissioning in 2018-19 within the above identified focus
areas. This will complement available data (including monitoring and evaluation of currently funded
services), contemporary Victorian and National policy and identified service and system barriers to
ensure alignment with local needs and the 2018-19 PHN guidelines and performance framework.
Services will be commissioned in the first and second quarters of 2018-19.
In addition, the approaches or mechanisms, i.e. enablers, that may be used to implement this activity
include: care navigation and access, quality improvement, health literacy, workforce development,
care pathways, and e-health. After hours initiatives will also be considered, as appropriate.
• People with chronic conditions.
Target population cohort • Whole of population.
• Identified priority populations.
NWMPHN utilises a range of mechanisms to facilitate consultation, including through the Community
Advisory and Clinical Councils. Specific consultation and advice will be sought from a range of relevant
strategic and local organisations and stakeholders, such as peak and professional bodies, State
Government and emergency and acute services. Existing NWMPHN Expert Advisory Groups may also
contribute to this work eg Mental Health.
Consultation - HSI Component Consumers and people with lived experience are core to the work we do. Therefore, significant
consultation activities are planned and will be completed by October 2018, using co-design and
patient journey mapping approaches. This will ensure that a full range of relevant stakeholders
including community members, primary care providers, health services, local government and
community health have genuine input in the design and development of interventions that may be
generated.
Collaboration with key stakeholders will occur throughout the commissioning process. Consequently,
the following stakeholders may be involved in prioritisation, planning, implementation, monitoring
Collaboration - HSI Component and evaluation of activities:
• NWMPHN regional and strategic partnerships and collaboratives
• Local Hospital Networks
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Activity Work Plan 2018-2019 (Core Funding, General Practice Support Funding, After Hours Funding) V1 – 16 April 2018 (D18-634620)• Community Health Services
• General Practice
• Residential Aged Care Facilities
• Pharmacy
• Allied Health
• Community based organisations
• Research institutes
• Peak and professional bodies
• Victorian Department of Health and Human Services
• Local government
• Other identified providers
Population Health, Procurement, Planning and Evaluation, General Practice and other primary care
HSI Component – Other
support, Care Pathways.
Indigenous Specific NO
1 July 2018 – 30 June 2019.
Duration Planning for this activity is occurring currently. Procurement and commencement of delivery will
likely occur in the second half of 2018.
Coverage NWMPHN region, with an initial focus on Wyndham, Hume, Melton.
All NWMPHN’s activity aligns with the NWMPHN Commissioning Framework. The approach
will therefore follow the NWMPHN commissioning cycle, including the develop insight, plan and
deliver and evaluate and improve phases. The iteration that occurs within each stage ensures
engagement, responsiveness to local need and continual improvement.
Commissioning method (if known) The activity will be commissioned in parts, after the needs of the community are further understood.
Evaluation of activities commissioned in 2016-2018 will also inform strategic planning, to ensure
evidence based and locally feasible delivery models continue to be implemented.
NWMPHN’s approach to market will be tailored to align with the local procurement context. An
approach to market will be developed and undertaken in line with best practice commissioning
8
Activity Work Plan 2018-2019 (Core Funding, General Practice Support Funding, After Hours Funding) V1 – 16 April 2018 (D18-634620)principles, and may involve extending or varying an existing contract, EOI, direct negotiation, request
for quote (RFQ) or RFT.
Decommissioning Not applicable
Proposed Activities
Activity Title / Reference (eg. CF 1) HealthPathways (CF 3)
Existing, Modified, or New Activity Existing
Select one of the following: Workforce
Program Key Priority Area
Needs Assessment Priority Area (eg. 1, 2, 3) NWMPHN Health Needs Assessment November 2017: Section 4, all priorities (pp. 69 to 77).
The aim of this activity is to ensure readily available access to up-to-date care pathways guidance on
Aim of Activity the HealthPathways platform, which allows us to achieve health outcomes for our community by
connecting our consumers and clinicians through seamless pathways of care.
NWMPHN will continue to commission services to facilitate primary care access to HealthPathways
Melbourne: an on-line evidence-based guidelines and referral pathways platform, to ensure the right
care for the patient, in the right place, at the right time.
Continued development of content for and promotion of the HealthPathways platform to a primary
care audience allows us to strengthen clinical decision making and simplify transitions of care. This
activity ensures that learnings arising from the development of care pathways, in collaboration with
Description of Activity sector partners, can be captured and translated for a primary care audience. It also ensures that the
HealthPathways platform is further developed as a credible source of content, thereby facilitating
initiatives that underpin transformation of the primary care setting, such as MyHealthRecord and
MyAgedCare.
Key content topics of development align with and further support broader training and education of
practitioners to better meet the needs of Children and Families (CF 1), as well as the Chronic
Conditions, Mental Health, Alcohol and Other Drugs and Suicide Prevention priority areas.
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Activity Work Plan 2018-2019 (Core Funding, General Practice Support Funding, After Hours Funding) V1 – 16 April 2018 (D18-634620)Promotion of the HealthPathways platform thereby offers a single channel to support many messages
directed to the primary care audience, which ultimately aim to improve health outcomes in North
Western Melbourne.
As a complement to broader care pathways work, this activity also continues to support the
development of statewide pathways that align with clinical practice guidelines and broader sectoral
reforms in partnership with the state government and its departments and agencies.
This activity complements HSI 3 (Care Pathways and Digital Health).
Target population cohort • Whole of population
NWMPHN utilises a range of mechanisms to facilitate consultation, including through the Community
Advisory and Clinical Councils. Specific consultation and advice will be sought from a range of relevant
strategic and local organisations and stakeholders, such as peak and professional bodies, State
Government and emergency and acute services. Existing NWMPHN Expert Advisory Groups may also
contribute to this work eg Mental Health and AOD.
Consultation - HSI Component Consumers and people with lived experience are core to the work we do. Therefore, significant
consultation activities are planned and will be completed by October 2018, using co-design and
patient journey mapping approaches. This will ensure that a full range of relevant stakeholders
including community members, primary care providers, health services, local government and
community health have genuine input in the design and development of interventions that may be
generated.
Collaboration will be utilised wherever possible throughout the commissioning cycle as NWMPHN
recognises that working in this way adds value and strengthens our reach. Mutually meaningful
collaboration is pursued and maintained in a systematic way across the organisation, which facilitates
timely access to existing and new collaboration approaches.
NWMPHN will work with identified stakeholders relevant to the activities outlined, which will include
Collaboration - HSI Component
general practice and other primary care providers (including but not limited to allied health), local
hospital networks, community health organisations, local government, peak and professional bodies.
Consumers and people with lived experience are core to the work we do. Therefore, consumer
consultation and co-design methodologies will be employed to ensure service users have genuine
input in the design and development of interventions that may be generated.
10
Activity Work Plan 2018-2019 (Core Funding, General Practice Support Funding, After Hours Funding) V1 – 16 April 2018 (D18-634620)State government departments and agencies are kept informed, partner with us to fund state-wide
pathway development and implement reforms at the primary care interface using the
HealthPathways platform as a key enabler and are becoming increasingly involved in pathway
development and endorsement of pathways.
We are working with other Victorian and Tasmanian PHNs implementing HealthPathways to develop
shared approaches that increase the development efficiency and reach of HealthPathways content.
Population Health, Procurement, Planning and Evaluation, General Practice and other primary care
HSI Component – Other
support, Care Pathways.
Indigenous Specific NO
Duration 1 July 2018 – 30 June 2019.
Coverage NWMPHN region
Commissioning method (if known) Direct negotiation
Decommissioning Not applicable
11
Activity Work Plan 2018-2019 (Core Funding, General Practice Support Funding, After Hours Funding) V1 – 16 April 2018 (D18-634620)1. (c) Planned PHN activities
– Core Operational Funding Stream: Health Systems Improvement 2018-19
– General Practice Support Funding 2018-19
Proposed Activities
Activity Title / Reference (eg. HSI or GPS) Population Health Planning (HSI 1)
HSI/GPS Priority Area Select one of the following: Population Health Planning
Existing, Modified, or New Activity Existing Activity, OP 2
The aim of this activity is to support and deliver integrated population health planning through
developing a strong and comprehensive approach across the commissioning cycle.
This will include developing NWMPHN’s capacity to undertake the cyclical process of identifying needs,
working with others to co-create solutions, directing resources towards these solutions, monitoring and
reviewing this activity and then re-commencing the cycle.
More specifically our key objectives are to:
Aim of Activity 1. Support NWMPHN’s organisational strategic and commissioning goals through the provision of
accurate, timely and relevant population health data, analysis and information
2. Continue to build organisational capacity and capability regarding population health, evidence
informed development, data translation, research and evaluation
3. Continue to build and maintain our data infrastructure (storage, analytics, governance and
systems) to support population health data quality, integrity, security, reporting and use
4. Continue to ensure NWMPHN is the leader and key data custodian for population health
information about our region
NWMPHN will continue to ensure we have a team with the right skills and abilities to support internal
and external stakeholders to undertake population health analysis and planning. This includes the
Description of Activity
identification of need in the region, supporting the development of evidence based plans, and
supporting the robust monitoring and evaluation of impact and outcome measures.
12
Activity Work Plan 2018-2019 (Core Funding, General Practice Support Funding, After Hours Funding) V1 – 16 April 2018 (D18-634620)Work that will be undertaken to support the development of this approach includes:
• NWMPHN will work with state and local governments, as well as Local Hospital Networks and
other partners such as community health services and Primary Care Partnerships, to increase
the alignment of population health data and planning in the North Western Melbourne region.
• NWMPHN will continue a partnership with the Department of Health and Human Services
(DHHS) Regional Offices which includes a shared population health analyst position working
across both organisations’ offices.
• NWMPHN will build its research and evaluation capacity and capability, including progressing
the collaboration agreement with Monash University through the appointment of a shared role.
• NWMPHN will continue to use data to drive quality improvements in primary care, through for
example better utilising PATCAT General Practice data to support the Quality Improvement
Practice Incentive Payment (QIPIP) and other initiatives.
• NWMPHN will continue to develop and finesse tools and guidance to support evidence based
program development and delivery across the commissioning cycle. This includes the broader
processes to identify needs, prioritise and co-create solutions.
A comprehensive approach to population health analysis and planning contributes to better
collaboration across primary health care and between primary and secondary care.
Supporting the primary health care sector
This will in turn contribute to improved coordination of services and focus of effort on targeted
populations and areas of need.
Collaboration will be utilised wherever possible throughout the commissioning cycle as NWMPHN
recognises that working in this way adds value and strengthens our reach. Mutually meaningful
collaboration is pursued and maintained in a systematic way across the organisation, which facilitates
timely access to existing and new collaboration approaches.
NWMPHN will develop and build on relationships with key stakeholders from across the region to
Collaboration provide a platform to improve collaboration across the commissioning cycle. As well as ongoing
engagement activities, this will include one on one consultations with major health service providers,
and running group engagement activities, with a strong voice for consumers and carers.
Collaboration will be undertaken with the following key stakeholder to participate in data sharing,
prioritisation and planning:
• Local hospital networks
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Activity Work Plan 2018-2019 (Core Funding, General Practice Support Funding, After Hours Funding) V1 – 16 April 2018 (D18-634620)• Community health organisations
• Local Government Authorities
• Primary Care Partnerships
• Aboriginal community controlled health agencies
• Consumer and carer representative agencies
• General Practice
Population Health Planning is a continuous and iterative enabling activity supporting work across the
organisation and region. The Health Needs Assessment (HNA) is one key tool developed annually to
support our planning and commissioning. Below are the steps involved in its development, consultation
and delivery.
Duration
• 2018 Health Needs Assessment (HNA) planning and development – July/August
• 2018 HNA consultation and engagement – Sept/October
• 2018 HNA submission – November
• HNA dissemination and development of specific related collateral – Jan-Mar 2019
NWMPHN region, with a focus on priority populations that may be most at risk of poor health
Coverage outcomes, such as refugee and asylum seekers, homeless people, Aboriginal and Torres Strait Islanders
as well as our significant culturally and linguistically diverse (CALD) communities.
Population health planning aims to support the NWMPHN vision of improved health outcomes for
Expected Outcome everyone in our community.
Proposed Activities
Activity Title / Reference (eg. HSI or GPS) Stakeholder engagement and collaboration (HSI 2)
Select one of the following: System Integration
HSI/GPS Priority Area
If Other, please provide details:
Existing, Modified, or New Activity Existing Activity
Aim of Activity NWMPHN is committed to ensuring collaborative stakeholder engagement is embedded in the culture
and core functions of the organisation. We recognise that strong and meaningful engagement and
14
Activity Work Plan 2018-2019 (Core Funding, General Practice Support Funding, After Hours Funding) V1 – 16 April 2018 (D18-634620)collaboration with our stakeholders is critical to achieving our commissioning objectives and our
mission to strengthen primary health care and connect services across the system. We also believe that
effective engagement delivers benefits for all participants and will ensure we capitalise on and build
upon the collective efforts of stakeholders across the health system to improve health outcomes for
our communities.
The aim of this activity is to:
• Enhance our stakeholder engagement capacity and embed good engagement practice into our
commissioning approach and core business
• Develop and maintain successful collaborative relationships across the health and care sector,
including with service providers, peak and professional bodies, local and state government,
and with consumers and local communities.
• Build robust sub-regional health system collaborations to leverage resources across the
primary and acute care interface and local, state and commonwealth governments to achieve
improvements against the quadruple aim and greater impact for the communities of North
Western Melbourne.
NWMPHN has a strong commitment to ensuring the involvement and engagement of diverse and
priority populations. This includes ensuring those whose voices may be seldom heard are included in
our processes. Priority populations include Aboriginal and Torres Strait Islander People, Culturally and
Linguistically Diverse communities, including refugees and asylum seekers, and LGBTIQ communities.
NWMPHN will build on a strong history of multi-faceted stakeholder engagement, established trusted
relationships and robust partnerships. Prioritised activity in 2018-19 will include:
Stakeholder engagement and relationship development:
• Ongoing broad mapping and analysis of stakeholders, utilising insight gained to support
Description of Activity stakeholder management approaches.
• Ongoing enhancement of our Clinical and Community Advisory Councils and expert advisory
groups, to ensure meaningful input in our commissioning strategy and decision making.
• Targeted stakeholder engagement and co-design on chronic conditions and mental health
needs, and scoping to inform local strategies to support implementation of children's and
families’ activity.
• Consultation on the health needs assessment and activity work plans.
15
Activity Work Plan 2018-2019 (Core Funding, General Practice Support Funding, After Hours Funding) V1 – 16 April 2018 (D18-634620)• Producing a quarterly commissioning communiqué outlining commissioning intentions,
procurement plans and progress of commissioning processes. This will be a key tool to
communicate with our provider market and other stakeholders.
Regional Collaborations:
• Continued auspice of strategic sub-regional collaborations, including:
o The Collaborative, a partnership between The Royal Melbourne Hospital, two
community health services and NWMPHN, working to improve health outcomes for
people with chronic illness in inner north west Melbourne. The priority for 2018-19 is to
reduce avoidable hospital utilisation through improved integration and community-
based models of care.
o The Better Health Plan for the West, which utilises a collective impact approach to build
a strong health system in Melbourne’s west to deliver better health and improved
wellbeing for local people. The priority area for 2018-19 is children and families, with a
focus on the first 1000 days. Subsequent priority areas include mental health and
chronic conditions
• Ongoing participation in formal networks and collaborations, including The Victorian
Community Care Advisory Committee, the Melbourne Ageing Research Centre, Better Health
North East and Shared Vision for the North.
• Ongoing participation in local government health and wellbeing plan consultations and local
hospital network Primary Care and Population Health Advisory Committees.
The NWMPHN approach supports the primary health care sector as it:
• Allows relevant parties to be part of the solution
• Enhances risk management practices
• Ensures initiatives are aligned to local need, resulting in better planned, targeted and
informed commissioning activities
Supporting the primary health care sector
• Improves decision-making
It also provides:
• Greater transparency and therefore understanding of decision-making processes
• Improved collaboration and opportunities for partnership
• Opportunities to leverage existing community skills and expertise
16
Activity Work Plan 2018-2019 (Core Funding, General Practice Support Funding, After Hours Funding) V1 – 16 April 2018 (D18-634620)• Increased capacity to innovate
• Greater community understanding of NWMPHN’s role in primary health care and sector
reform, and
• Formalised, open, consistent and transparent communication channels.
The approach to strategic sub-regional collaborations aims to strengthen primary care to improve the
health outcomes of people in the community. The partnership work primarily focusses on preventive
and integrated care programs, connecting services across the health system and allowing people to
receive care close to home to avoid unplanned hospital presentations and admissions.
Collaboration will be utilised wherever possible throughout the commissioning cycle as NWMPHN
recognises that working in this way adds value and strengthens our reach. Mutually meaningful
collaboration is pursued and maintained in a systematic way across the organisation, which facilitates
timely access to existing and new collaboration approaches.
Consumers and people with lived experience are core to the work we do. Therefore, consumer
consultation and co-design methodologies will be employed to ensure service users have genuine input
in the design and development of interventions that may be generated.
NWMPHN approach to collaboration and engagement is underpinned by the IAP2 model. Best practice
in public engagement is now influenced by the Spectrum of Public Participation developed by the
International Association of Public Participation. This spectrum includes five levels of participation,
Collaboration Inform, Consult, Involve, Collaborate and Empower. These are each identified below.
Healthcare Professionals - General Practice Staff, Allied Health Providers, Specialists, Other healthcare
providers [Inform, Consult, Involve, Collaborate and Empower]
Government and Funding Bodies - Ministers/Politicians, Commonwealth Government Departments,
State Government Departments, Local Councils, Philanthropic Organisations, Corporate Entities
[Inform, Consult, Involve and Collaborate]
Research, Evaluation and Policy - Academic Institutions Research Organisations, Consultancy Firms,
Think Tanks [Inform, Consult and Collaborate]
Governance - Clinical Council, Community Advisory Council, Expert Advisory Groups [Collaborate and
Empower]
17
Activity Work Plan 2018-2019 (Core Funding, General Practice Support Funding, After Hours Funding) V1 – 16 April 2018 (D18-634620)Community Participants - Consumers, Patients, Carers, People with lived experience, Priority
Populations, Community Leaders [Inform, Consult, Involve, Collaborate and Empower]
Community Organisations and Networks - Non-Government Organisations, Peak Bodies, Primary Care
Partnerships, Regional Collaborations, Corporate Providers, Advocacy Groups [Inform, Consult, Involve,
Collaborate and Empower]
Corporate Stakeholders - Regulatory bodies, Auditors, Accreditation Providers, External Support
Providers, Contractors and suppliers [Inform and Consult]
Health and Residential Services - Public Health Services/Local Hospital Networks, Private Hospitals,
Community Health Services, ACCHOs, Residential Aged Care Facilities, Rehabilitation Facilities [Inform,
Consult, Involve, Collaborate and Empower]
Media - Print, Online, Radio [Inform].
Duration 1 July 2018 – 30 June 2019
NWMPHN region. While there is a significant focus on sub-regional collaborations to drive a population
health approach to achieving our objectives, it should also be noted that national engagement is also a
Coverage
core feature of this work as we have key relationships with national peak and professional agencies and
sector leaders.
The expected outcome of this activity is continued enhancement of the reach and depth of our
engagement and relationships with stakeholders. We will monitor:
• Intersectoral planning and collaboration.
Expected Outcome • Increased ability to implement shared approaches and initiatives.
• Increased use of consistent targets and outcomes for improvement in the care of the shared
community.
• Participation in networking and shared events.
18
Activity Work Plan 2018-2019 (Core Funding, General Practice Support Funding, After Hours Funding) V1 – 16 April 2018 (D18-634620)Proposed Activities
Activity Title / Reference (eg. HSI or GPS) Care Pathways and Digital Health (HSI 3)
Select one of the following: System Integration
HSI/GPS Priority Area
If Other, please provide details:
Existing, Modified, or New Activity Modified NP 6.3 and NP 6.4
To maintain and further develop care pathways to enable improved integration and primary care capacity
to optimise health outcomes and patient experience. This includes providing alternatives to hospital-
Aim of Activity based care, contributing to a reduction in potentially preventable hospitalisations. These pathways of
care will operate across the acute and primary care interface and be supported by technical solutions and
digital health technologies.
NWMPHN will build on previous care pathways and digital health activities to:
• Understand current integrated and person-centred care needs of local communities, informed by
the Health Needs Assessment and sector and community consultation.
• Understand sub-optimal service utilisation, including primary care type presentations to
Emergency Departments and potentially preventable hospitalisations.
• Use co-design methodologies to further develop and redesign technology supported pathways of
care to address areas of need within the community where care can be safely provided close to
Description of Activity the person’s home, improving quality of care across the system, increasing efficiency and
improving patient and provider experience.
• Document pathways of care on the HealthPathways platform, making locally agreed, consistent
and evidence-based pathways of care readily accessible to clinicians across the acute and primary
care interface.
• Implement strategies to enable or reinforce evidence-based pathways of care, such as primary
care capacity building and driving meaningful use of digital health technology to improve decision
making and timely information sharing.
Implementation of technology supported evidence-based pathways of care builds primary care capacity
and supports providers to navigate the complex local health system.
Supporting the primary health care sector
Care pathways will be primary care-led, working in partnership with key stakeholders across the acute
and primary care interface and informed by consumer experience. This will ensure primary care and
19
Activity Work Plan 2018-2019 (Core Funding, General Practice Support Funding, After Hours Funding) V1 – 16 April 2018 (D18-634620)consumer needs are met, relationships are developed and maintained and that primary care is supported
to operate at the top of their scope.
Collaboration will be utilised wherever possible throughout the commissioning cycle as NWMPHN
recognises that working in this way adds value and strengthens our reach. Mutually meaningful
collaboration is pursued and maintained in a systematic way across the organisation, which facilitates
timely access to existing and new collaboration approaches.
NWMPHN will work with identified stakeholders relevant to the activities outlined, which will include
Collaboration
general practice and other primary care providers, local hospital networks, community health
organisations, local government, peak and professional bodies.
Consumers and people with lived experience are core to the work we do. Therefore, consumer
consultation and co-design methodologies will be employed to ensure service users have genuine input in
the design and development of interventions that may be generated.
Duration 1 July 2018 – 30 June 2019
Coverage NWMPHN region.
The expected outcomes align with the quadruple aim of:
• Improving patient outcomes and patient experience, through delivery of technology supported,
Expected Outcome evidence-based, integrated and person-centred pathways of care
• Improving clinician experience, through improved relationships, work flows and role clarity
• Lower cost of health care, through a reduction in potentially preventable hospitalisations.
Proposed Activities
Primary Care Support: supporting a team-based and integrated approach to delivering person-centred
Activity Title / Reference (eg. HSI or GPS)
primary health care (HSI 4)
Select one of the following: Other Practice Support
HSI/GPS Priority Area
If Other, please provide details:
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Activity Work Plan 2018-2019 (Core Funding, General Practice Support Funding, After Hours Funding) V1 – 16 April 2018 (D18-634620)Existing, Modified, or New Activity Modified NP 1.1, NP 1.2 and NP 1.3
The aim of this activity is to improve population health outcomes through supporting a team-based and
integrated approach to delivering person-centred primary health care across the region. This
complements the activity within the General Practice Support Schedule to ensure reach to more than
Aim of Activity 550 general practices across the region and by supporting other primary care providers, including allied
health practitioners.
Population health and service data will inform this activity, which will be targeted to support identified
priority health needs and populations.
NWMPHN is currently undertaking a review of our support to primary care to achieve improved
population health outcomes, patient experience, care team wellbeing and cost effectiveness. The
outcome of this work will inform this activity from the second half of 2018-19.
In the interim, activity will include data driven quality improvement, workforce development and
capacity building. This will be supported by the development of tools and resources, provision of
networking, education and training opportunities, as well as identifying and utilising a range of
communication channels and mechanisms to achieve the stated objectives. The focus will be to:
Description of Activity • Build the capacity and capability of primary care providers and care teams to identify and
respond to lifestyle physical and mental health related risk factors
• Build the capacity and capability of primary care providers and care teams to better manage
chronic and co-morbid conditions
• Work to reduce medicine-related problems and potentially preventable hospitalisations
• Support and improve the delivery of person-centred care to all patients, including addressing
the needs of diverse and priority populations, and improving the coordination of care between
providers and settings.
This activity is focused solely on supporting the primary health care sector to deliver evidence-based
integrated and person-centred care. Primary care providers will be consulted as key stakeholders in this
Supporting the primary health care sector work. This consultation will provide insight in to the way they wish to be able to provide care for their
patient populations and contribute to better outcomes by taking a team-based approach to delivering
person-centred care, and integrating care across the primary health care system.
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Activity Work Plan 2018-2019 (Core Funding, General Practice Support Funding, After Hours Funding) V1 – 16 April 2018 (D18-634620)Collaboration will be utilised wherever possible throughout the commissioning cycle as NWMPHN
recognises that working in this way adds value and strengthens our reach. This is critical to driving a
team-based and integrated approach to delivering person-centred primary care.
Collaboration Mutually meaningful collaboration is pursued and maintained in a systematic way across the
organisation, which facilitates timely access to existing and new collaboration approaches. NWMPHN
will therefore work with identified stakeholders relevant to the activities outlined, which may include
but not limited to: peak and professional bodies, academic and training institutions, local hospital
networks and community health organisations.
Duration 1 July 2018 – 30 June 2019
Coverage NWMPHN region
The expected long-term outcomes of driving a team-based and integrated approach to delivering
person-centred primary health care include:
• Increased capacity of primary care providers and care teams to identify and respond to lifestyle
related risk factors
Expected Outcome • Increased capacity of primary care providers and care teams to better manage chronic and co-
morbid chronic conditions
• A reduction in medicine-related problems and potentially preventable hospitalisations
• Improved coordination of care between settings
• Improved workforce capacity to deliver evidence-based integrated and person-centred care.
Proposed Activities
Activity Title / Reference (eg. HSI or GPS) General Practice Support (GPS)
Select one of the following: General Practice Support
HSI/GPS Priority Area
If Other, please provide details:
Existing, Modified, or New Activity Existing Activity: OP1
To encourage continuous improvement and quality of care in general practice whilst improving access
Aim of Activity
and population health outcomes across the region.
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Activity Work Plan 2018-2019 (Core Funding, General Practice Support Funding, After Hours Funding) V1 – 16 April 2018 (D18-634620)To ensure local adoption of best practice methods to support general practice to address the quadruple
aim in the context of the Australian primary healthcare sector, NWMPHN is undertaking a
comprehensive review of our current model and approach to providing primary care support. The
outcome of this work will inform continuous improvement of this activity from the second half of 2018-
19.
NWMPHN will:
• Provide direct support through a range of engagement methods such as face to face visits,
education and training (including leadership development) and multi-method communication
depending on the needs of practices, to promote and improve the uptake of practice
accreditation and the Practice Incentive Program (PIP). This will be supported by the
development and implementation of a range of tools and resources for practices to practically
apply in their local settings.
Description of Activity • Upskill general practice to better understand and meaningfully use digital health systems to
improve care delivery by improving processes and use of patient information. This work will be
complimented by the MyHR expansion program and the QIPIP readiness strategy.
• Support the development of health information management systems by providing the data,
tools and training opportunities required to support the collection and application of
meaningful data to drive quality improvement activity.
• Implement strategies, making full use of the existing training and funding structures, to
facilitate networking with general practice and other providers as appropriate to support a data
driven approach to quality improvement and system integration. This allows for peer
mentoring, networking and opportunities to share best practice methods to innovate practice.
• Utilise the resource and experience of the organisation and its identified enablers to build the
capacity of general practice in delivering evidence-based and optimal care through digital
health solutions, appropriate care navigation and access, workforce development, care
pathways and quality improvement in primary care.
The primary health care sector will be directly supported through a range of engagement methods,
Supporting the primary health care sector including but not limited to; face to face in practice support visits, education and training sessions,
quality improvement activities, communities of practice, networking and peer support groups,
electronic and telephone support. This will be delivered by both the dedicated primary care support
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Activity Work Plan 2018-2019 (Core Funding, General Practice Support Funding, After Hours Funding) V1 – 16 April 2018 (D18-634620)team and staff from across the organisation, as NWMPHN sees this activity as a key enabler to
achieving the PHN objectives.
The dedicated primary care support team will use their core skills such as quality and safety (including
accreditation), data quality and digital health, to strengthen engagement with the primary health care
sector and improve the quality of care provided to patients.
Activity will also include where appropriate other primary care providers such as allied health and
pharmacy to reinforce and influence quality of care and continuous improvement, see Primary Care
Support: Supporting a team-based and integrated approach to delivering person-centred primary health
care (HSI 4).
Collaboration will be utilised wherever possible as NWMPHN recognises that working in this way adds
value and strengthens our reach. Mutually meaningful collaboration is therefore pursued and
maintained in a systematic way across the organisation, which facilitates timely access to existing and
new collaboration approaches.
Collaboration NWMPHN will continue to collaborate with general practice as a key stakeholder for informing best
practice methods and developing improvement systems that deliver improved quality of care.
NWMPHN will also work with other identified stakeholders relevant to the activities outlined, which
may include but is not limited to: peak and professional bodies, academic and training institutions, local
hospital networks, local government authorities, community health organisations and consumer and
carer representative agencies.
Duration 1 July 2018 – 30 June 2019
Coverage NWMPHN region
The expected outcomes are:
• Improved patient experience – Patients will experience improved quality of care as a result of
the support provided to general practice to deliver integrated person-centred care and embed
Expected Outcome best practice continuous quality improvement.
• Improved population and patient health outcomes – Improved population health outcomes will
be demonstrated using data quality tools, the uptake of accreditation and the PIP, and due to
the support provided in managing local population health needs, such as chronic and co-morbid
conditions.
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Activity Work Plan 2018-2019 (Core Funding, General Practice Support Funding, After Hours Funding) V1 – 16 April 2018 (D18-634620)• Improved value of care – The impact that quality improvement activity has on business
development will improve the value of care received by patients, and support reduced
potentially preventable hospitalisations.
• Improved primary care provider experience – Relevant and timely engagement and co-design
methods, peer support opportunities and workforce development will drive improved general
practice experience.
3 HSI funding is to be used to deliver core functions within the PHN program such as population health planning, system integration and stakeholder engagement, as well as support to general
practice which is not funded under the General Practice Support Funding Schedule. PHNs are able to use flexible funding to commission referral or health pathways activities (including non-
staff costs such as ‘Streamliners’) but all associated PHN staff costs must be funded from HSI funding. HealthPathways activity to be undertaken by commissioned services should be
separately identified as a Core Flexible Activity in 1. (b) Planned PHN activities – Core Flexible Funding Stream 2018-19.
PHNs cannot commission frontline services using HSI funding. PHNs may use HSI funding to subcontract specific activities under this stream, for example a health data analyst or consultant
may be contracted to identify priorities for improved care coordination. Contracted or consultant arrangements are particularly appropriate for time-limited and specialist projects.
Practice support is to be provided through HSI funding and must be primarily delivered through PHN employees. Practice support cannot be commissioned out to a third party. Practice
Support includes general practice support not funded under the General Practice Support Funding Schedule and support provided by your PHN to other practices, eg. allied health practices.
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Activity Work Plan 2018-2019 (Core Funding, General Practice Support Funding, After Hours Funding) V1 – 16 April 2018 (D18-634620)4. (a) Strategic Vision for After Hours Funding
The aim of the NWMPHN after hours program is to improve the efficiency and effectiveness of after
hours primary health care (AHPHC) for patients, particularly those with limited access to health
services, as well as improving access through effective planning, coordination and support for
population based AHPHC.
Systematic data analysis and stakeholder consultation is being undertaken to look at AHPHC access
trends and community need. The data analysed so far, including learnings from the 2017 NWMPHN
Health Needs Assessment, has identified the following:
Drivers
• Melton is anticipated to have the highest population growth in the 15 years between 2016
and 2031 with a 92.5% increase, followed by Melbourne with 69.3% and Wyndham with
64.0%. Brimbank is forecasted to have the slowest rate of growth with 13.0% increase.
• The areas with highest proportion of 0 – 4 year olds are Wyndham, Melton and Hume.
• Melbourne, with 45%, had the highest proportion of its population born in a predominately
non-English speaking country. This was followed by Brimbank, with 42.2%, and Maribyrnong
with 32.5%.
• Brimbank, Maribyrnong, Hume and Darebin have the largest proportions of people with
poor English proficiency.
• Melbourne has the highest proportion of people experiencing homelessness with 18.5%,
followed by Brimbank (15.8%) and Darebin (10.4%).
• In comparison to the 2011 Census, the population who were experiencing homelessness in
Melbourne (LGA) increased by 86.3%.
• Nine out of the 13 NWMPHN LGAs have rates of psychological distress higher than the
Victorian average.
Unmet demand
Emergency Department attendances
• NWMPHN’s region is currently below the Australian average in after hours emergency
department attendances;
• There are lower per capita rates of Primary Care Type presentations to emergency
departments in the peri-urban areas of Macedon Ranges and Moorabool;
• Hobson’s Bay and Maribyrnong have the highest rates of category 4 and 5 emergency
department presentations in the after hours period;
• The inner Melbourne areas have the highest rates of category 4 and 5 emergency
department attendances. This data has a general inverse correlation to the after hours GP
usage data;
• The age groups with the highest percentage of category 4 and 5 after hours emergency
department attendances are 0 - 4 year olds and 20 – 24 year olds.
Ambulance Victoria data
• Darebin has the highest rate of non-emergency ambulance calls;
• The highest rates of non-emergency ambulance calls made across the NWMPHN region are
made by older adults.
After hours primary health service availability
• Melbourne had the greatest number of primary health services open in the after hours
period per 10,000 population in the catchment at 29.5, followed by Yarra (27.3). The lowest
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Activity Work Plan 2018-2019 (Core Funding, General Practice Support Funding, After Hours Funding) V1 –
16 April 2018 (D18-634620)number of primary health services open in the after hours period per 10,000 population was
in Moorabool and Melton, with 6.4 and 8.5, respectively.
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Activity Work Plan 2018-2019 (Core Funding, General Practice Support Funding, After Hours Funding) V1 –
16 April 2018 (D18-634620)4. (b) Planned PHN Activities
– After Hours Primary Health Care Funding 2018-19
Proposed Activities - copy and complete the table as many times as necessary to report on each activity
Activity Title / Reference (e.g. AH 1) AH 1.1: Managing an unwell child in the after hours period
Existing, Modified, or New Activity Modified
NWMPHN Health Needs Assessment November 2017: Section 4, pages 59 – 77
Needs Assessment Priority Area (e.g. 1, 2, 3)
NWMPHN After Hours Gap Analysis and Recommendations: Interim Report
The aim of this activity is to improve the confidence of parents/caregivers in managing an unwell child
Aim of Activity
in the after hours period
NWMPHN will commission a provider to deliver a program that will improve the ability of
parents/caregivers to manage an unwell child in the after hours period. This activity will focus on
parents and caregivers of children aged 0 – 4 years of age.
The educational/training program delivered by the provider should consider the following elements;
• identifying common, low complexity conditions that a child may experience;
• describing what interventions can be provided to a child for these conditions (where
appropriate); and/or
• deciding on an appropriate after hours service (if appropriate); and
Description of Activity • contacting/accessing after hours services.
A provider will be expected to design and deliver a program which;
• Is sustainable/has sustainable elements (post funding)
• Is evidence based
• Is outcome focussed
• Is accessible for parents/caregivers who have English as an additional language
• Can be imbedded/implemented through existing community based groups and/or
organisations
• Includes appropriately targeted language/training materials
• Includes a strong evaluation/monitoring framework
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Activity Work Plan 2018-2019 (Core Funding, General Practice Support Funding, After Hours Funding) V1 – 16 April 2018 (D18-634620)Parents and caregivers of children aged 0-4 years
Target population cohort
Culturally and Linguistically Diverse (CALD) communities
NWMPHN utilises a range of mechanisms to facilitate consultation, including through the Community
Advisory and Clinical Councils, and expert advisory groups.
Consumers and people with lived experience are core to the work we do. The commissioned gap
analysis and recommendation work and the after hours community awareness campaign included a
significant amount of community engagement and consultation. Interviews, focus groups and online
Consultation
surveys with community members (parents/caregivers of children aged 0-4 years) and key sectors
informants (paediatric clinicians) guided development of this activity.
This activity will also include genuine key stakeholder input in the procurement process. Additionally,
the commissioned provider(s) will be expected to consult with community members when designing
and implementing their activity.
Collaboration with appropriate stakeholders will occur throughout the commissioning process.
Stakeholders may include community health services, general practice, local hospital networks,
Collaboration pharmacy, allied health, community-based service providers, Ambulance Victoria, medical deputising
services, community members/carers, telephone based support services, Department of Health and
Human Services and other identified providers.
Indigenous Specific NO
Duration Planning/Procurement: November 2018 – March 2019
Contract: April 2019 - October 2020
Wyndham
Coverage Melton
Hume
All NWMPHN’s activity aligns with the NWMPHN Commissioning Framework. This activity
will therefore follow the NWMPHN commissioning cycle, including the develop insight, plan and
Commissioning method (if relevant)
deliver and evaluate and improve phases. The iteration that occurs within each stage ensures
engagement, responsiveness to local need and continual improvement.
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Activity Work Plan 2018-2019 (Core Funding, General Practice Support Funding, After Hours Funding) V1 – 16 April 2018 (D18-634620)You can also read
