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| Program | SERVICE TO GPS | | Goal | To improve the efficiency and effectiveness of the organisational & clinical components of General Practice | | Strategy | Practice Management Activities emphasising education, inter-practice networks and accreditation support. |
| Outcomes | Activities | Indicators | Results&Commentary |
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Improved business and practice management.
Practices accessing available funding streams (SIP/PIP etc). |
Provide and/or facilitate access to CPD and other education and/or training activities in business and/or practice management. |
Reach: 15% of MDGP GPs attend at least one education activity in this 12 month period.
Impact: 85% of those attending rank the activity as very good to excellent.
Outcome: An overall increase in accessing CDM and consequently government funding initiatives eg SIP/PIP, EPC, Medicare plus |
Seminars & Education:
Good Health with Physical Activity = 11 participants
Diabetes in GP = 4 participants
Update Continence & Prolapse = 12 participants
Immunisation Update on Vaccines = 30 participants
Pharmaceutical Issues for Nurses = 9 participants
Aged Care Information Night = 22 participants
Early Detection of Prostrate Cancer = 30 participants
Infection Control & Reaccreditation = 40 participants
Paediatric Asthma Management = 10 participants
Antithrombotic Therapy in GP = 43 participants
Know your Awards = 39 participants
Infection Control -= 40 participants
Immunisation Education = 43 participants
Aged Care Update = 23
Community Referrals made Easy = 7 participants
Know Your Awards Practical Session = 15 participants
GP Harp Information = 10 participants
Update on Travel Medicine = 42 participants
Continence in the Community = 8 participants
Lifestyle Interventions in GP = 11 participants
Wound Management = 27 participants
GP Panels DONS = 8 participants
Aged Care GP Panel Update = 23 participants
Aged Care GP Panel Review = 11 participants
Heartbete = 32 participants
Path Mgt & Recalls = 25 participants
Broadband for Health = 25 participants
225 unique practices represented at education events. 56% from Melb Div, from other Divs.
Promotion and advice on all incentive programs (including mental health)
30 accreditation related practice visits
6 packs of EPC package/templates mailed out
EPC data
MBS item - Health assessments:
700 = 145
702 = 159
712 = 43
MBS items - Care Plans
720 / 722= 1,115
724/726/728 = 206
PIP data:
72 participation in PIP
(54% of practices)
Provision of Data 100%
Electronic Prescribing 94.4%
Electronic data 95.8%
24 Hour Access 98.6%
ø After Hours at least 15 hours within practice = 56.9%
ø After Hours- of all hours care for practice = 20.8%
Student teaching = 15%
SIP data:
Asthma sign- on = 87.5%
Cervical Screening = 90.2%
Diabetes sign-on = 86.1%
Practice Nurse Incentive = 8.3%
DCGP Project:
8/18 practices provided data on SIP & PIP activity for diabetes. 7/8 practices reached PIP target of >20% patients with annual cycle of care and received outcome payment.
Data obtained on care plans from all patients showed increase in number of patients with current care plan from 17.6% (114/647) at baseline. 26.2% (146/557) at first review, 27.2% (1-4/383) at second review, and to 41.9% (90/215) at third review.
Auditing our evaluations shows that over 85% participants consistently rate Melb Division education events as good or very good.
49% GPs attend at least one education activity
Increase in accessing CDM and other PIP initiatives is evident.
The increase of approximately .2% is consistent with the national average in PIP participation increases.
A GP Care Plan Advisor was appointed during the year as another option for GPs seeking support. |
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| Increased number of general practices who are accredited and re-accredited |
Target unaccredited practices & those facing reaccreditation providing assistance to reach re/accreditation |
Reach: 100% of accredited clinics due for reaccreditation undertake reaccreditation in any one-year.
100% of small/solo practices are contacted with a view to promoting accreditation.
Impact: 90% of accredited practices are accessing SIP/PIP payments.
Outcome: 30% of unaccredited practices (solo/small practices) register for accreditation.
100% of accredited practices are re-accreditation. |
100% of the unaccredited 27 Solo and small practices were contacted with the view to promote accreditation
Practices registered for accreditation
July 04 = 81
Dec 04 = 90
As at June 05 = 93
Increase of 15 % in 12 month period
88% of accredited practice accessing sip/pip. 1% increase on previous year.
30% unaccredited practices have expressed an interest in accreditation.
Practices notified and or information on due date for reaccreditations in the next phase after 30 June 05
(AGPAL)
2005 = 10
2006 = 15
2007 = 24
2008 = 7
Reaccreditation support tools:
ø Ready reckoner
ø Self assessment support
ø Direct observation
Checklist/timeline
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| Program | SERVICE TO GPS | | Goal | To improve the efficiency and effectiveness of the organisational & clinical components of General Practice | | Strategy | Information Management emphasis both in and out of practice education and support. |
| Outcomes | Activities | Indicators | Results&Commentary |
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| Increased uptake and utilisation of IT/IM by practices |
ø Site Visits
ø Telephone advice of a training nature
ø Interdivisional and MDGP Information and training sessions
ø Resource development and distribution
ø Encourage use of email as a means of communication |
Reach: 20% of practices visited by division staff to provide software training and/or system audits and recommendations.
20% of practices attend divisional or Interdivisional information or training sessions.
20% of uncomputerised practices will be targeted for approach by division staff to discuss benefits of computerisation.
Impact: Increased awareness of benefits of computerisation and increased knowledge of system requirements. Increase in practices embracing electronic communications.
Increased interest in computerisation.
Outcome: 80% of practices already using computers will report increased and secure usage of computers and IM. A number of previously uncomputerised practices will computerise. |
1.1.2.1 BOIMH
Templates for Medical Director, Genie and Med Tech have been developed. These allow GPs to use the program and refer patients using an integrated process to compliment their existing paperless systems
DCGP Project:
Of 6 practices that provided data 5 practices have disease register as part of clinical software system, 4 have active practice computerised recall system, and 2 have active recall system operated by DCGP nurses.
13% practices visited with software training and/or audit and/or recommendations for improved practice.
IT Usage survey commenced. Results inconclusive at reporting time.
172 (40%) GPs attended IT/IM training event or received practice visit.
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| Program | SERVICE TO GPS | | Goal | To improve the efficiency and effectiveness of the organisational & clinical components of General Practice | | Strategy | Communication Activities - diverse strategies increasingly utilising electronic means. |
| Outcomes | Activities | Indicators | Results&Commentary |
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| MDGP communications read widely by GPs and practices within the catchment. |
Produce and distribute effective and informative general practice news through user friendly channels and other media formats |
Reach: 100% practices receive weekly fax outs and print media.
100% of practices (with internet facility) invited to use MDGP Web Site for resources, divisional news updates and download e-news
Impact:
GPs receive relevant timely and time-critical information from Division.
Over 12 month period MDGP Web site provides a bank for all templates, resource material and essential links relevant to general practice management.
Outcome:
GPs recognise MDGP communications as key source of relevant information. |
receive weekly fax outs and print media. Including regular mail outs.
Divisional Newsletter
3 Editions (Aug 04, Dec 04 & Apr 05)
100% of practices (with internet facility) invited through news in practice survey forms and weekly fax outs to use MelbDiv Web Site for resources, divisional news updates and download e-news through creation and transmission of efax@mdgp <mailto:efax@mdgp> (weekly faxouts)
19 new subscriptions to receive Dr Care weekly faxout in email format via the Practice Survey 2004
Presently 36 registered to receive email.
A practice staff quarterly bulletin mailed to 167 practices
Web developed as a bank for templates and resources (including direct links to current medical information)
Updates weekly (Friday)
Other promotional publications (eg posters) 3 large colour posters for ADGP forum
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| Program | SERVICE TO GPS | | Goal | To improve the efficiency and effectiveness of the organisational & clinical components of General Practice | | Strategy | QUM Activities |
| Outcomes | Activities | Indicators | Results&Commentary |
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| GPs and Pharmacists optimise quality use of medicines. |
GPs participate in NPS program on PPIs, Hypertension & Antithrombolytics.
Pharmacists & GPs attend joint CPD program on HMR & PPIs |
Reach: 50% of GPs participate.
80% pharmacies visited and involved in HMR
Impact: HMRs are efficiently conducted and less medication related admissions to hospitals.
Prescribing of PPIs, antihypertensives and Antithrombolytics is clarified and guidelines adhered to.
Outcome: Improved prescribing and collaboration between GPs and pharmacists |
GP surgery visit presentations on PPIs, Hypertension and Antithrombotic evidence based guidelines.
Visits to pharmacies and HMR contacts with pharmacists
Total year
ø 43% unique GPs received QUM visit
ø - 100% HIC registered pharmacies visited.
64% increase on last period for MBS item 900.
HIC data indicates improved use of antibiotic and PPI prescribing in Melb Div catchment.
Participate on three hospital pharmacy liaison projects; involved with Aged Care Panels medication management discussions & GP education, and participate in Royal Melbourne Hospital/ACH discharge & medication consultations.
DCGP Project:
Rate of current HMRs at baseline 2.5% (16/633), 1.3% (7/557) at first review, 5.5% (21/382) at second review, and 5.1% (11/215) at third review. HMR increasing in the area.
MBS item no. 900 - HMR- is well utilised in the MelbDiv where appropriate. Figures comparing MelbDiv to other Divisions are low but accounted for by our demographics.
Involvement in the Pharmacy liaison projects at RMH and St Vincent's has been positive but extrapolation of data to admissions prevented is not possible at this stage.
Positive progress towards this outcome evident. |
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| Program | SERVICE TO GPS | | Goal | To improve the efficiency and effectiveness of the organisational & clinical components of General Practice | | Strategy | Hospital Liaison |
| Outcomes | Activities | Indicators | Results&Commentary |
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| GP representation on CBD hospital planning and liaison committees |
Recruitment and training of GP members to participate as MDGP Division representatives on hospital planning committees. |
Reach: MDGP representatives participate in each Melbourne CBD hospital's planning and liaison committee.
Impact: GP Division representatives contribute to hospital policy and planning. |
GPs participate on Royal Melbourne, Royal Women's, Royal Children's & St Vincent's Hospital planning & liaison Committees.
Decision to focus participation on key hospitals within catchment. Strengthening relationship with RMH, RWH, St Vincent's & RCH to reflect resource constraints and availability of GPs. |
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| Improved communications between GPs and hospitals |
Develop GP/hospital interface protocols |
Reach: MDGP representatives participate on key committees dealing with GP/hospital interface.
Impact: Representation and advocacy of GPs on strategic hospital committees. |
MelbDiv staff participate on area GPLO working group - covering 6 HARP funded GPLOs. MelbDiv staff participate on 8 committees hosted by 3 hospitals. MelbDiv receives minutes on a further 2 hospital committees.
MelbDiv lobbying DHS for inclusion of hospital KPIs around GP interface.
Developing care plan protocols, templates, and communication pathways as consequence of Harp programs - Restoring Health, Coach, Community Asthma, Alert, Community Pharmacy, Falls Prevention, Diabetes, Integrated Disease Management.
GP Forum with St Vincent's - Aged Care and Discharge interface - 15 GPs participating.
MelbDiv contributes to development of IT/IM templates for referral at St Vincent's.
Clear indications from hospitals of importance of GP interface reflected in this year's strategic public documentation circulated to Div for comment by 4 hospitals prior to publication, invitations to participate in key advisory and planning committees, and through DHS mandated inclusion for GP involvement. |
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| Program | SERVICE TO GPS | | Goal | To improve the efficiency and effectiveness of the organisational & clinical components of General Practice | | Strategy | Local Community Liaison |
| Outcomes | Activities | Indicators | Results&Commentary |
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GP involvement and representation in the primary care sector planning activities
Improved linkages between GPs and the primary care sector |
Develop with PCPs GP patient referral and feedback protocols inclusive of EPC etc |
Process: MVM PCP and NPCP have MDGP GP representatives on key committees.
Impact: Patient feedback and referral protocols developed.
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A directory of community, public and private mental health services available within the MelbDiv catchment area is developed. To be web based, and downloadable.
MelbDiv representatives active in PCP partnership - attend steering committees, Information Connectivity Technology meetings. Two training sessions on SCTT tools with PCP conducted, targeted at practice nurses. Small grant project with PCP on SCTT concluded during period.
PCP participates with MelbDiv on key hospital committees especially around referral and feedback.
GPs strongly represented in PCP activities. Linkages improving through active participation. Division shares premises with PCP. |
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| Program | SERVICES BY GPS TO PATIENTS | | Goal | To improve the clinical management of patients | | Strategy | Cardio Vascular Health emphasising GP education and provision of information on available services. |
| Outcomes | Activities | Indicators | Results&Commentary |
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| Increase GP awareness of CV risk factors |
Provision of GP peer education on cardio vascular risk factors, and active script information.
GPs participate in Coach Program. |
Reach: 15 % of GPs participate in CV education activities over 12 month period.
Impact: Increase self–rated GP understanding of CV risk factors and application of Medicare Initiatives.
Outcome: Increase in number of Medicare Plus payments received by clinics for dietician services.
Increase in number of patients referred for COACH Program. |
Two CV education events. 11% of GPs attended over 12 month period.
71% solo GPs were contacted by telephone. 7 requested a practice visit, 15 required further information, 29 either didn't require any further information/ not interested/
uncontactable. The program is not relevant to an additional 6 practices.
5 MelbDiv GPs contacted the Cardiac Coach for further information regarding The COACH Program.
7 practice visits were conducted at 2 group practices and 2 solo practices. 3 of these practices were from MelbDiv postcodes.
2 medical record searches were conducted. For one of the medical record searches letters were written to 99 patients with 40 (40%) patients subsequently joining the program.
2 initial assessment sessions were conducted at a GPs surgery.
122 patients have been enrolled in The COACH Program in the current reporting period. A total of 298 patients are now enrolled in the program.
19 GPs have referred patients into The COACH Program over this period. Of these 11 are from group practices and 8 are solo GPs.
Allied health services (including dieticians) were introduced onto the MBS on 1 July 2004.
HIC figures indicate that in Victoria there has been a steady increase in Medicare claims for dieticians services since their introduction. Claims have increased from 21 in July to a high of 903 in May.
The evaluation indicated 80% of GPs felt The COACH Program was relevant to their day to day practice and felt they now had the tools and could confidentially recruit patients into a lifestyle intervention program.
Despite extensive promotion of CV education activities through divisional media and telephone contact with practices we were unable to reach the target of 15% MelbDiv GP participation in these activities over this reporting period. This maybe due to: GPs feeling they are adequately informed regarding CV, GP lack of time to attend education session, timing/location of education sessions.
GPs highlighted lack of time and already managing their patients with CHD adequately as reasons why they didn't require any further information regarding the program.
The Division has recently appointed a GP advisor in relation to EPC item numbers and care plans. This may subsequently lead to an increase in referrals to dietician services.
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| Program | SERVICES BY GPS TO PATIENTS | | Goal | To improve the clinical management of patients | | Strategy | Diabetes Alliance activities emphasising GP and practice staff education and building practice systems. |
| Outcomes | Activities | Indicators | Results&Commentary |
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| Improve management of patients with diabetes |
Provision of GP peer education on diabetes management guidelines |
Reach: 20% of GPs participate in GP peer education activities on diabetes management.
Impact: Increase self-rated GP understanding of diabetes management guidelines.
Outcome: 5% increase in the number of Diabetes Cycle of care SIP payments received by practices in the MDGP boundaries. |
As part of the Diabetes Alliance Group (DAG), ran 2 education evenings in August 2004 for GPs and practice staff on diabetes related topics.
Two sessions: 47 GPs and 4 practice staff, 6 DNEs and 1 nurse.
On 23 June 05 ran an evening seminar on Obesity Management in Diabetes- the Options. 33 GPs attended.
19% GPs participate.
As part of DAG, ran an 8-week course in September-October 2004 for practice nurses on Diabetes Management in the general practice setting.
8 relevant articles relating to diabetes were written up in weekly fax out.
An increase of 14.3% in the number of Diabetes SIP payments were made this year.
Evaluation from participants showed positive responses with comments suggesting the information gained will lead to changes in behaviours.
Evaluations were very positive with GPs stating they had improved their confidence in dealing with obesity in their clients with diabetes
All participants indicated the course would prove valuable in assisting them to improve diabetes care in the general practice setting. |
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| Program | SERVICES BY GPS TO PATIENTS | | Goal | To improve the clinical management of patients | | Strategy | Respiratory Activities emphasising education of GPs and practice staff, and access to support services. |
| Outcomes | Activities | Indicators | Results&Commentary |
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| Improve management of people with asthma. |
Provision of GP peer education on asthma management guidelines |
Reach: 20% of GPs participate in GP peer education activities on asthma management
Impact: Increase self-rated GP understanding of asthma 3+ plan and Community Asthma Project (CAP)
Outcome: 20% increase in number of GPs referring to CAP.
10% increase in GPs receiving Asthma SIP payments. |
As part of the Respiratory Alliance Group (RAG) 2 education evenings were organised GPs and p/staff on asthma related topics.
Session 1: cancelled on day of session due to presenter illness.
Session 2: attended by 22 GPs and 2 practice nurses.
Ran an Active Learning Module for GPs on Asthma and COPD. Attended by 40 GPs.
9 relevant articles relating to respiratory issues were written up in the weekly fax out.
An education session with practice nurses to promote CAP, utilizing the Asthma 3+ using the asthma educators conducted.
A decrease of 6.3%
Of Asthma SIP payments were claimed in this 12 month period
Evaluations showed a very high level of satisfaction for all sessions during the modules.
Funding for the GP Engagement Officer was not granted therefore there has not been a member of the project to specifically target GPs and promote the CAP.
GPs state that the asthma SIP is difficult to complete, as the patients are less inclined to return to the GP for the 3rd visit especially when they are feeling well.
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| Program | SERVICES BY GPS TO PATIENTS | | Goal | To improve the clinical management of patients | | Strategy | Mental Health Module emphasising GP education and integration/collaboration with Mental Health Services in the community. |
| Outcomes | Activities | Indicators | Results&Commentary |
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| Improve primary care management of patients with mental health problems. |
Provision of GP peer education in mental health chronic disease management. |
Reach: 30% of GPs participate in GP education mental health management.
Impact: Increase self-rated GP understanding of mental health management guidelines, application of MBS mental health chronic disease item, access to Primary Mental Health Teams.
Outcome: 10% increase in number of GPs registered for Level 1 & Level 2 MBS Mental Health Items.
20% increase in number of GPs accessing PMHT.
20% increase in access to focussed psychological strategies for eligible patients. |
GPs registered for MBS items increased 25% on last reporting year, and GPs actively referring increased by 233%.
Access to FPS increased 650% on last reporting year.
GPs completing 3-step mental health process increased 144% on last reporting year.
Through its communications channels, Melb Div promoted 20 education activities to GPs, hosted by mental health agencies.
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| Program | SERVICES BY GPS TO PATIENTS | | Goal | To improve the clinical management of patients | | Strategy | Gender Health emphasising GP education and provision of information on available services. |
| Outcomes | Activities | Indicators | Results&Commentary |
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| Improve management of Gender Health |
Provision of GP peer education in management of STIs. |
Reach: 20% of GPs participate in GP peer education on STIs.
Impact: Increase self-rated GP understanding of the management of STIs.
Outcome: Improved detection of STIs |
Education update on Incontinence and Prolapse. Attended by 9 GPs, 2 practice staff and 2 continence foundation staff.
Early Detection of Prostate Cancer in GP. Attended by 16 GPs.
Participated in the interdivisional annual dinner for women GPs. 12 MDGP GPs attended.
19 relevant articles relating to issues on gender health were written up in weekly fax out.
An increase of 7.2% of cervical screening SIP payments were claimed in this reporting period
Incontinence education showed a positive response from participants. Follow up telephone questionnaires with 5 of the GPs about 8 weeks later showed that they are still practicing as they always have, indicating that their clinical practice has not been altered by this education event.
Evaluations of Prostate Cancer education showed a positive response and 14 GPs chose to do pre and post testing for 5pph |
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| Program | SERVICES BY GPS TO PATIENTS | | Goal | To improve the clinical management of patients | | Strategy | Practice Nurse Services - implement a support program for GPs accessing Practice Nurse Services, and for practice nurses themselves with a view to increasing the integration of Practice Nurses in general practice. |
| Outcomes | Activities | Indicators | Results&Commentary |
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| Increase the utilisation of Practice Nurses in General Practice. |
Develop a practice nurse service at MDGP. |
Reach: All practices receive promotional information and/or visits with regard to MDGP Practice Nurse Service.
90% of practice nurses in MDGP catchment attend at least one network meeting.
Impact: Increase in PIP/SIP payments and utilisation of MBS practice nurse items.
Outcome: Improved patient care services by GPs accessing the services of a Practice Nurse. |
Completion of the Div 1 practice nurse recruitment and induction kit project.
100% of nurses on the MelbDiv database were surveyed to evaluate the perceived value of the current education sessions offered. 44% of nurses on the database responded to the survey. Information gathered via this survey will help plan next years meetings and provide information for planning future training strategies
Commencement of Initial planning for the proposed “Trial a Nurse” Scheme.
Information gathered from contact with 100% of practices that don't employ nurses but are eligible for the PIP PN subsidies and other practices who don't employ. Provided feedback that has been used in the planning and evaluation of a proposed trial for a model of service that will allow easier access to use of nurses in general practice for solo and small practices
Joint practice nurse network sessions with NDGP continue to run with 6 being conducted over the reporting period. The 6 sessions offered training and information to practice nurses on Paediatric Asthma Management (11 participants), Health Promotion - Good Health with Physical Activity (12 participants) and Pharmaceutical Issues for Nurses in General Practice (8 participants) Community Referrals made e-zy (6 participants) Continence in the Community (9 participants) Wound management in 05 (26 participants)
Feedback from participants rated the sessions high as useful learning forums. 4 of the 6 sessions were presented by community projects and as well as being able to offer education had the opportunity to promote their services.
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| Program | SERVICES BY GPS TO PATIENTS | | Goal | To improve the clinical management of patients | | Strategy | DAG Harp Program - Diabetes Co-management in General Practice (DCGP) - colocation of diabetes nurse educators in practice. |
| Outcomes | Activities | Indicators | Results&Commentary |
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| Improve management of patients with diabetes in Co-management (DCGP) |
Provision of diabetes nurse educator for participating practices to support enhanced case management in general practice, and provide diabetes education and after hours support and advice. |
Reach: 3-5 general practices participate in Diabetes Co-management in General Practice project over 12 month period
Impact: 3-5 general practices provide enhanced case management and, diabetes education and after hours support for people with diabetes.
Outcome: Patients with diabetes from 3-5 general practices have improved care and health outcomes, and reduced unnecessary use of hospital services. |
6 General Practices are participating in DCGP project in Melbourne Division area.
Diabetes related emergency presentations all patients:
Proportion of patients having any diabetes related emergency presentation reduced by 96% and rate of presentation reduced by 30% since program commencement (Sep 02). Proportion of high-risk patients having any diabetes related emergency presentation reduced by 213% and rate of presentation reduced by 13% since program commencement.
Proportion of patients having any diabetes related hospital admission reduced by 265% and rate of admission reduced by 1% since program commencement.
Proportion of high-risk patients having any diabetes related hospital admission reduced by 333% and rate of admission reduced by 34% since program commencement.
100% of patients admitted to program receive education in management of their diabetes.
Targets reached re practice participation.
Practices providing enhanced case management, diabetes education and after hours support for people with diabetes.
Hospital admissions reducing over time.
Patient health outcomes increased significantly over period of program. |
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| Program | POPULATION HEALTH | | Goal | To develop strategies and capacity within General Practice to address population health issues | | Strategy | Immunisation Activities including education across ages, and practice support to practices with low rates. |
| Outcomes | Activities | Indicators | Results&Commentary |
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| Increase age-appropriate immunisation rates |
Provision of GP peer education on age-appropriate immunisation guidelines (including childhood, older adult and vaccination schedules, and communicable disease alerts).
Provision of strategies to increase childhood immunisation rates.
Practice visits to practices with low immunisation rates. |
Reach: 10% of GPs participate in GP peer education on age-appropriate immunisation
Impact: Increase in self-rated GP understanding of current Immunisation Schedule and catch-up protocol.
100% of practices visited by Immunisation Program staff offered data cleaning education.
Outcome: At the end of the 12-month period, 2% increase age-appropriate immunisation rate for GPII registered practices in the MDGP boundaries. |
Update on Vaccines for GPs and Practice staff. Attended by 19 GPs and 14 p/staff.
Immunisation Education attended by 22 GPs and 17 practice staff.
Travel Medicine Update Attended by 33 GPs and 10 practice staff.
55 visits made to 40 different practices.
Of the GPII registered practices,
22 % with <90% coverage received a practice visit around data cleaning, strategies for managing children overdue for immunisation.
Of the GPII registered practices, 16 % with >90% coverage received a practice visit to discuss immunisation issues in general and provide resources.
Of the practices visited, 100% offered data cleaning education and 38% took up offer of assistance.
Division coverage rate from May 2005-87.3%
New resources and updated information from external resources (eg. DHS and ACIR) written up in the weekly fax out.
23 relevant articles relating to immunisation issues written up in weekly fax out.
Immunisation resources and related links regularly updated to website.
MDGP continues as the lead agency for the WMRDQO program and coordinates the steering committee meetings every 3 months.
Involved in the NMRDQO program as well. Attend meetings every 3 months and assist Yarra and Moreland councils with providing reports and data cleaning.
DCGP Project.
Rates of Fluvax immunisation for baseline, first, second, and third review were 62.4% (867/1390), 70.4% (615/873), 73.8% (361/489), 77.9% (166/213)
Rates of Pneumovax immunisation for baseline, first, second, and third review were 44.0% (610/1385), 54.5% (475/872), 62.6% (306/489), 66.5% (141/212)
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| Program | POPULATION HEALTH | | Goal | To develop strategies and capacity within General Practice to address population health issues | | Strategy | Emergency & Disaster Planning - consultation and policy development with GPs and state/federal governments. |
| Outcomes | Activities | Indicators | Results&Commentary |
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| Engagement of GPs in E&D Planning particularly in readiness for 2006 |
Develop a protocol for GP engagement in E&D planning |
Reach: 100% GPs consulted on E&D planning.
Impact: Increase in understanding of DHS and Federal equivalent re the GP and MDGP roles in the event of E&D.
Outcome: Protocol for GPs included in state and federal E&D plans. |
Division participated in 2 meetings with DHS with a view to establishing the role of GPs in E&D. DHS provides information for MelbDiv newsletter. Participated in GPDV forum with DHS and other stakeholders. Contact with local politicians on need to address GP role by 2006. Division commented on DHS E&D Plan review material.
DHS proving hard to engage - agreed to joint GP workshop on D&E and GP role but impact of Tsunami diverted their attention. |
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| Program | POPULATION HEALTH | | Goal | To develop strategies and capacity within General Practice to address population health issues | | Strategy | Aged Care - through GP education establishment of GP networks and liaison with residential and other aged care facilities. |
| Outcomes | Activities | Indicators | Results&Commentary |
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| Improve GP engagement in Aged Care Services |
Establish an Aged Residential Care Working Group including community and other agency representatives. |
Process: Aged Care Working Group develops model for GP Aged Care participation.
Impact: Relationships developed between Aged Residential Care facilities and GPs. |
See Aged Care Program 5.
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| Program | POPULATION HEALTH | | Goal | To develop strategies and capacity within General Practice to address population health issues | | Strategy | Recalls - promote practice management of populations of patients at risk or with chronic conditions through enhanced information management (registers, recall, monitor cycles of care). |
| Outcomes | Activities | Indicators | Results&Commentary |
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| Improve population health screening and preventative activities. |
Education and training sessions:
ø IT/IM
ø Practice Support via accreditation |
20% of practices request visits IT/IM recalls. |
13.6% practices request and receive a total of 24 visits.
IT/IM education sessions x 5 for 172 GP participants.
Programs that actively encourage IT/IM (recalls and registers) via practice visits are NPCC, Diabetes Co Management, Coach Program, Immunisation, DAG/RAG.
GP, knowledgeable in use of registers and recalls, appointed to consult directly with GPs. 10 individual consultations in first month of engagement.
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| Program | POPULATION HEALTH | | Goal | To develop strategies and capacity within General Practice to address population health issues | | Strategy | ATSI - establish links with ATSI health agencies and incorporate ATSI health issues in education as relevant. |
| Outcomes | Activities | Indicators | Results&Commentary |
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| Promote and support access by Koori community to GP Services. |
Establish links with Koori agencies and develop relationship. |
Reach: Initiate meetings with 100% Koori agencies within MDGP area.
Impact: Incorporate Koori health service activities for inclusion in MDGP activities and plans. |
MelbDiv active in supporting VAHS accreditation process. MelbDiv signatory to VACCHO MOU.
Division invites VAHS to access all program areas.
Develop relationship with other Koori agencies - meeting at North Central Metropolitan Primary for ATSI Access Peer Support Network & Care Partnership
Currently discussing VHAS interest in participating in the NPCC and Coach Programs. |
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| Program | POPULATION HEALTH | | Goal | To develop strategies and capacity within General Practice to address population health issues | | Strategy | Health Activities for Culturally & Linguistically Diverse patients |
| Outcomes | Activities | Indicators | Results&Commentary |
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| Increase support for GPs providing services to CALD patients. |
Source and deliver relevant specific language resources. |
Reach: 100% CALD GPs contacted regarding available relevant information.
Impact: Self reported satisfaction with resources. |
BOIMH
Clinical Psychologists contracted for the program can service patients who speak eight other languages and have good experience of working with an array of cultural backgrounds.
Coach Program sources language specific material from peak agencies, and invites family members to translate for the dietician where appropriate.
Division web links GPs to patient resources in multiple languages, availability promoted via faxout and practice staff.
DCGP Project identified 15.0% (236/1576) patients with diabetes at baseline as requiring an interpreter, of which 19.5% (46/236) received a professional interpreter and 53.4% (126/236) received a bilingual nurse.
At first review 9.0% identified as needing interpreter 15.8% (142/898) of which 6.3% (9/142) received professional interpreter and 73.2% (104/142)n received bilingual nurse.
Established relationship with Trans Cultural Psychiatry Unit. Further development work planned for 05-06.
No specific data on GPs satisfaction with resources collected.
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| Program | DIVISION MANAGEMENT & OPERATIONS | | Goal | To achieve best practice organisational management. | | Strategy | Internal Accreditation |
| Outcomes | Activities | Indicators | Results&Commentary |
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| MDGP reaches and maintains high level of accreditation |
Implement accreditation. |
MDGP receives accreditation ranking with reputable agency within 24-month period. |
Division reviewed for accreditation with QICSA 28 & 29 June. Advised verbally we were successful.
Registration and receipt of Accreditation achieved within 12 month period. |
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| Program | DIVISION MANAGEMENT & OPERATIONS | | Goal | To achieve best practice organisational management. | | Strategy | Business systems |
| Outcomes | Activities | Indicators | Results&Commentary |
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MDGP has effective and efficient business systems
MDGP is financially stable meeting all legal requirements |
Appropriate policies and procedures developed.
Monthly and annual financial reports provided to Board.
Comply with financial accountability requirements of DoHA, other funding bodies and Consumer Affairs.
Auditor reports to Board on results including recommendations as appropriate. |
Appropriate policies and procedures exist for all business systems.
Monthly and annual budget to actual with >15% variance narrated. Current Ratio >1 each month.
Annual audited financial statements and other reports provide to DoHA and Consumer Affairs by due dates and in proscribed formats.
Auditor conducts annual audit. |
Detailed Finance, Human Resource, OH&S, Governance, and Office Policies and Procedures have been developed and implemented consistent with best practice.
The monthly accounting routine includes reported variance analysis, amongst other relevant and useful detail. The Board receives monthly and annual financial reports.
The Division meets its compliance and reporting requirements, and these are captured and articulated via a compliance checklist which is provided to the Board on a monthly basis.
The auditor conducts an interim and annual audit in Feb and Aug and his recommendations are presented to the F&A Committee which reports directly to the Board.
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| MDGP has a management structure that provides clarity of roles and responsibilities, decision making authority and reporting pathways |
Appropriate diagrammatic structure developed and circulated. Roles and responsibilities defined on written document. |
Organisational chart printed and distributed.
Roles and responsibilities articulated and circulated. Position descriptions for all positions distributed. |
The organisational chart is available in the Division's Policies & Procedures Manual and on the web. Roles and responsibilities of all staff are reviewed annually, and all staff have a copy of their position description.
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| Program | DIVISION MANAGEMENT & OPERATIONS | | Goal | To achieve best practice organisational management. | | Strategy | Planning and Reporting |
| Outcomes | Activities | Indicators | Results&Commentary |
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| MDGP implements and maintains sound planning, evaluation & reporting practices |
Undertake strategic planning involving stakeholders. Collect information on stakeholders on regular basis via practice support visits team. |
Process: 60% of members involved in strategic planning through annual survey, practice support visit pro forma, GP focus groups, and strategic planning sessions.
Document participation of non-GP stakeholders in planning processes.
Impact: MDGP strategic plan is owned by Division Board and membership and accepted by DoHA. |
A detailed work plan exists for each program/project of the Division. The work plan is informed by the needs of the community it aims to serve. This information is collected via focus groups (6 in 04-05), and surveys (2 in 04-05), and external evaluations (1 in 04-05). Two programs include feedback mechanisms for patients. Staff underwent 3 training sessions in evaluation techniques and their application in the Division context. The Division engaged a researcher to undertake in-depth research into the needs and perceptions of 24 GPs. 100% of practices were contacted to update their data on the database.
66% of practices were visited generating 325 visits in total.
Staff collect information on survey forms opportunistically during visits.
The Division developed a plan to engage a wider group of stakeholders as part of the next round of strategic planning.
Annual Planning Process planned for Sep 05. |
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| Program | DIVISION MANAGEMENT & OPERATIONS | | Goal | To achieve best practice organisational management. | | Strategy | Governance |
| Outcomes | Activities | Indicators | Results&Commentary |
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| MDGP engages in good governance processes and protocols, which are transparent. |
Implement Division management and accountability structure.
Develop and maintains Board code of ethics and governance manual
Board members receive relevant training on governance and strategic management issues. |
Board meetings receive program reports and Finance & Audit Committee reports.
Board code of ethics and governance manual produced.
Minimum of 50% of Board members attending training in governance and strategic management over the 12 month period. |
Each meeting of the Board receives the F&A Committee reports. Staff regularly provides reports to the Board on their programs/projects and the Board Calender allows for each staff members to present to the Board at least once per annum.
The Board has developed and maintained a code of ethics and governance manual.
Seven Board members received training in governance during the year. A process to introduce Board appraisals has been developed.
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| Program | DIVISION MANAGEMENT & OPERATIONS | | Goal | To achieve best practice organisational management. | | Strategy | Membership |
| Outcomes | Activities | Indicators | Results&Commentary |
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| MDGP membership is engaged with, and satisfied by, the activities of the Division |
Practice support visits undertaken. GP focus groups utilised. |
Member survey returned by >35% of membership.
Indication of satisfaction of members evident in survey results. |
Seven GP focus groups engaging 136 GPs as participants were held.
The Annual Survey was replaced by an in-depth research project engaging 24 GPs. The results were not received by 30 June 05.
25% membership participated in focus groups and/or qualitative survey.
In depth survey resulted received Aug 05 - very interesting and Division is implementing many recommendations. The annual strategic planning, and regular Divisional planning activities, will be informed by the results. Overall the Division has a positive image in the minds of members. |
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| Program | DIVISION MANAGEMENT & OPERATIONS | | Goal | To achieve best practice organisational management. | | Strategy | Information Collection and analysis |
| Outcomes | Activities | Indicators | Results&Commentary |
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| Improve the knowledge of Division's demography and needs |
Collect information via Practice Support visits, annual survey and specific surveys |
Practice Support team collect information on 30% practices.
>35% membership return annual survey.
At least 2 targetted surveys distributed and collected, return rate >35%.
At least 2 GP focus groups held including non-GP stakeholders. |
66% unique practice visits undertaken
628 contacts recorded with practice staff.
100% practices provided demographic data and information on practice needs.
Two targeted surveys were distributed and collected - mental health and informed planning.
Seven GP focus groups held (cvd, mental health, aged care, practice nurse, hospital interface, IT/IM) engaging 154 GPs and practice staff.
Annual stakeholder forum planned for October 05. |
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| MDGP has an effective and efficient Human Resource system. |
Enhance the Human Resource system with reference to industry standards. |
Appropriate policies and procedures are developed and implemented. |
HR Policies and Procedures manual, consistent with best practice and in accordance with VHIA and GPDV advice, developed approved and implemented.
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| Program | AGED CARE | | Goal | To improve access of Aged Care Home residents to primary medical care | | Strategy | Develop effective operating model(s) for providing primary medical care to Aged Care Homes |
| Outcomes | Activities | Indicators | Results&Commentary |
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| Needs of Aged Care Homes within the division are identified and understood. |
Conduct comprehensive needs analysis by:
ø Surveying Aged Care Homes within the division
ø Visiting a sample of these homes
Interviewing Facility Managers/
Directors of Nursing |
Key priorities to address needs within the Division's boundaries have been identified. |
Needs analysis compromising of
ø Visits and interview to 32% of ACH
ø Survey to all ACHs 35% responded.
ø As a result of our consultation with the homes and with GPs in the division, 4 standing projects established to address issues
Some issues identified have been left until 2005 -6
The homes were generally very receptive to the GP Panels Initiative -
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| Barriers to GP involvement in Aged Care Homes are identified and addressed |
Consult with GPs by means of practice visits, telephone interviews and focus groups. |
ø Barriers to GP involvement have been identified.
Actions undertaken to address these barriers. |
The barriers to GP involvement identified through
ø GP Focus Group 3/9/05 8 attendees.
ø GP panels planning meeting 27/1/05
5 participants
Key barriers identified and 3 standing project teams developed to work on identified areas.
ø Medication management
ø After hours care
ø Education and training
Our research into the barriers to GP involvement in Aged Care Homes has shaped the project teams.
Barriers will be gradually addressed by various projects to be undertaken by the divisions in the next 2 years.
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| A “trial” GP Panel model is developed and piloted at a sample of Aged Care Homes within the division |
ø Identify “trial” sites (Aged Care Homes) for piloting GP Panel model.
Work with GPs and trial sites to develop and pilot-test the model. |
Aged Care GP Panel model is operational at several agreed trial sites (Aged Care Homes) |
GP Panel development has been variable.
Education standing project has developed 6 GP ACH teams to participate in mentoring project.
After hours has promoted ACH GP teams with GP quality meetings - still in development
It is anticipated that the GP Panel model will not be static but will evolve with time. |
| Set up Project Advisory Group to assist with the development of recruitment and selection processes for GP Panel membership |
Transparent and accountable processes for Aged Care GP Panel Member selection and appointment is established and maintained |
A Project Advisory Group (PAG) has been assembled for joint project MelbDiv and NDGP.
PAG and GP panels review meeting held June 2005
Terms of Reference for the PAG developed and documented in project records and folder. |
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| Links with other related service providers (eg. HARP funded Aged Care Outreach projects, Hospital-in-the-Home projects) are identified and strengthened |
ø Research and establish contact with related service providers.
ø Identify areas of cooperation (eg. In upskilling Panel GPs in care of the aged)
Build win-win relationships. |
Collaborative activities undertaken for mutual support and service promotion |
Initial meetings held with 5 stakeholder service providers to promote the project.
GP link Newsletter
2 editions to date circulated to 100% ACH.
Melbourne Health identified as priority.
3 meetings with GP liaison (& NWDGP)
1 meeting at Melb Health including
ø Heads of Medicine & Aged Care
ø Pharmacists 2
ø NUM
ø 1 ACP MelbDiv
ø 1 ACP NWMDGP
Sage project has engaged 7 providers of specialist-aged services to provide mentoring.
BECC provided 4 aged care GP training sessions
All other service providers have been supportive of the GP Panels Initiative
GP Liaison Officer at MH has resigned which may delay progress of this initiative. |
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| Program | AGED CARE | | Goal | To improve access of Aged Care Home residents to primary medical care | | Strategy | Implement an effective model for providing primary medical care to Aged Care Homes |
| Outcomes | Activities | Indicators | Results&Commentary |
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| GP Panel model is refined and gradually rolled out to other homes within the division. |
ø Review and refine “Trial” GP panel based on feedback from pilot sites, in line with Continuous Quality Improvement process.
Gradually roll out model to other Aged Care Homes which have agreed to participate in the initiative |
Number of Aged Care Homes actively participating in
GP panel arrangements |
6 ACHs have ongoing participation in GP panels project
ø 2 homes have held GP quality meeting
2 ACH have accepted referrals for GP services
This is a long-term outcome for the Initiative panel models are still in development.
Strategies developed to increase engagement of ACHs. |
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| Residents of Aged Care Homes have improved access to primary medical care |
Promote and implement GP Panel model to Aged Care Homes in division |
Participating Aged Care Homes' advice that access to GP services has improved |
ø 2 successful referrals to ACHs seeking GP services
ø 9 visits to ACH to promote project
ø 2 GP quality meetings at ACH
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| GPs attending Aged Care Homes are supported through continuing professional education. |
ø Identify training needs of GPs providing medical care to Aged Care Home residents.
Conduct educational and information sessions to meet these needs |
Number of continuing professional development and information sessions with an aged care focus |
GP training needs identified by needs analysis and education standing project.
3 GP panel aged care CPD sessions
4/9/04
12 participants
4/11/04
36 participants
20/4/05
25 participants.
SAGE program one mentee commenced, 6 enquiries.
4 BECC GP Aged Care training sessions.
29 participants
3 project teams registered as small group learning with RACGP.
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| Increase in uptake of Comprehensive Medical Assessment items, Case Conferencing and Care Plans for residents of Aged Care Homes |
ø Conduct information sessions to promote uptake of these items.
Work with GPs and Aged Care Homes to remove barriers to GPs' uptake of these items |
ø Increase in number of GP services provided to residents of participating Aged Care Homes.
ø Increase in number of GP services provided to residents as a proportion of aged care beds.
Increase in the number of residential aged care GP services as a ratio to Full Time Equivalent GPs |
Performance indicator 1 shows a 3.2% decrease in number of GP service provided to residents of aged care in the last year. Performance indicator 2 and 3 also show decreases of GP service numbers.
EPC and Medicare plus items promoted to GPs at CPD sessions - see above
Anecdotally ACH staff report CMA and RMMR have become common practice.
Decrease in GP services may be part of a wider trend.
1 ACH of 20 beds has closed in the region since the project has commenced. Prior closures have occurred and may impact on data. .
Indicator of more detail showing number of item such as CMA may be more helpful
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| GPs view Aged Care Homes as a meaningful and viable area of care (ie. one which they could consider as a “core business activity”) |
ø Work with Aged Care Homes to reduce barriers to GPs providing care to residents.
ø Promote Aged Care Homes as a meaningful and viable area of care for GPs.
Encourage Panel GPs to mentor younger GPs in providing care to residents of Aged Care Homes |
The age and gender of GPs providing residential aged care services in the region is more comparable with the national average |
SAGE Mentoring program to educate and support GPs to undertake on Aged care developed.
2 mentees commenced
Information to
2 ACH to promote the use of medical software.
2 articles in GP newsletter promoting aged care.
Performance indicator 4 shows a 21.8% increase in the proportion of women GPs and a 15.9% increase of GPs who are over 55 over the last 6 months.
This is a long-term outcome for the Initiative.
The data results appear to vary widely, for example 6 month date on proportion of GP s over 55 going from -22% to 15.9% in one year. It is difficult to draw conclusion from such figures, perhaps related to the small size of the catchment. |
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| General Practitioners have increased involvement in Aged Care Homes' quality activities. |
ø Consult with Aged Care Homes to identify requirements for GP involvement in quality improvement activities.
Where the need exists, facilitate GP participation in these processes |
ø Increase in the proportion of aged care homes that have GP involvement in their quality improvement activities.
Increase in aged care homes' satisfaction with the outcomes of GP involvement in their quality improvement activities. |
2 GP quality meetings facilitated at ACH.
ø 7 GP attendees
ø 2 pharmacy
Quality meetings promoted through newsletter and all meetings and events.
At the request of the ACH or GP or panel a quality meeting is held to allow GPs and ACH staff to work together on issues. All attending GPs and pharmacists invited. |
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| Effective partnerships and collaboration are established and maintained between GPs, Divisions and aged care homes |
Promote and implement GP Panel model to Aged Care Homes in the division. |
ø Communication and partnerships are established and maintained between GPs and participating Aged Care Homes.
ø Aged Care Homes and GPs are working effectively together to improve access to medical care for residents of aged care homes.
Aged Care homes' advice that Aged Care GP Panel is undertaking work to address key concerns. |
GP Panel link Newsletter - 2 editions to all ACH
Mentoring program
6 mentoring teams of GP ACH developed
Hosted DHS training pilot for ACH on medication management.
2 GP quality facilitated by divisions at ACHs.
Invitations sent to staff of ACHs for appropriate Divisional education
GP panel project team staff attend ACAS ACH network meeting within NDGP
ACH reps participated with Division and Melb Health in project work on discharge.
At GP panels review meeting- GPs reported increased collaboration with ACH s.
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Facilitate the establishment of aged care network comprising Aged Care Homes, GPs and other stakeholders to provide mutual support and share information/
resources |
Residential aged care networks are established and supported within the division |
1 ACH DON /Managers GP panel meeting.
Newsletter for DONs / managers circulated to all ACHs
Formal establishment of network delayed to new reporting period. |
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| Program | AGED CARE | | Goal | To improve access of Aged Care Home residents to primary medical care | | Strategy | Review and refine GP Panel model on a continual basis |
| Outcomes | Activities | Indicators | Results&Commentary |
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| GP Panel model is dynamic and evolving, based on needs of homes and changing project circumstances. |
Conduct regular reviews of GP Panel model and refine model, as necessary |
The Aged Care GP Panel model is built on and amended in light of the Initiative's development |
2 PAG meetings held.
Regular monthly report to CEOs with review of project.
Original plans have been adjusted as the project develops, reviews resulted in improving and maximising engagement with ACH and GPs to achieve goals in the light of resources available and effort required
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