Program Details for the year 2003 - 2004

Division Details | Plan & Report Summary


ProgramBUILDING CAPACITY IN GENERAL PRACTICE
GoalTo improve and sustain the quality and efficiency of general practice
StrategyProvide general practice with the necessary skills, knowledge and information to assist them in improving practice capacity
OutcomesActivitiesIndicatorsResults&Commentary
Increased capacity within General Practice to respond to the changing health environment Promote and provide access to relevant educational opportunities Number of opportunities provided to GPs
Evidence of services provided		 77 educational opportunities provided to GPs 2003 -2004.

1 GP Business Advantage 14th July 2003;
2 Competency in the Older Person 14th July 2003;
3 EBM Workshop 21st July 2003;
4 Leadership Weekend 21st July 2003;
5 NPS Psychogeriatrics Case Study 21st July 2003;
6 Incontinence Education Evening 4th August 2003;
7 Vascular Surgery Education Evening; 18th August 2003;
8 NPS Polypharmacy Case Study 18th August 2003;
9 NPS Educational Visit Antibiotics 18th August 2003;
10 Course in Clinical Trials 25th August 2003;
11 Satellite Broadcast- Cervical Screening & Breast Cancer in Indigenous Women 8th September 2003;
12 Dementia Education Evening 8th September 2003 ;
13 Older Persons Mental Health Seminar 15th September 2003;
14 GP Eye Skills Workshop 22nd September 2003;
15 Mental Health Familiarisation Training 22nd September 2003;
16 Dr Link Course in Mental Health 22nd September 2003;
17 Workplace Health & Safety Training 22nd September 2003;
18 Satellite Broadcast on Dementia 29th September 2003;
19 Diabetes Education Day 29th September 2003;
20 Disability Short Course Modules 29th September 2003;
21 NPS Case Study on Drinking Problems 6th October 2003;
22 Mental Health Workshop 6th October 2003;
23 Prostate Cancer Update - St As6th October 2003;
24 Breast Cancer Update - St As 6th October 2003
25 St Andrew's Diabetes Update 27th October 2003;
26 ALSO Training Program in Obstetrics 27th October 2003;
27 Assessment Care Review W'shop for Gatton practices 21st October 2003;
28 Working Together for Better Mental Health Outcomes Workshop 27th October 2003;
29 Case Study on Managing a Drinking Problem 3rd November 2003;
30 post Natal Depression Update 3rd November 2003;
31 Musculoskeletal training 3rd November 2003;
32 Palliative Care Education Program 17th November 2003;
33 Introductory EBP - Evidence Based Practice 17th November 2003
34. OTD Fellowship Study Group 24TH Nov 2003,
35. Aged Care - Not a Trivial Pursuit 1st Dec 2003,
36. Better Outcomes in Mental Health Level 2 8th Dec 2003 36. Business Advantage Risk Management 26th January 2004
37. Paediatrics, Obstetrics and Gynaecology 26th January 2004
38. LMA Postgraduate Weekend 26th January 2004
39. Immunisation Unravelled 26th January 2004
40. NPS Analgesics in Musculoskeletal Pain Educational visit and Case Study evening 26th January 2004
41. RHEF Satellite Broadcasts: alcohol problems 2nd February 2004
42. CDM 2nd February 2004
43. Aboriginal Health workers and chronic disease 2nd February 2004
44. mental health issues for young people 2nd February 2004
45. HIV, Hepatitis C and sexual health issues for aboriginal and Torres strait islander people 2nd February 2004;
46. NPS Depression in General Practice Clinical Audit 2nd February 2004;
47. Addictive Substances - 10 week program 16th February 2004;
48. Sources for quick, quality answers to clinical questions 8th March 2004;
49. STAHR Research Conference @ USQ 8th March 2004;
50. Stem Cell Research Presentation 8th March 2004 ;
51. Dual Diagnosis Networking Seminar 8th March 2004 ;
52. Child Psychiatry Grand Rounds: Sexual Abuse 8th March 2004 ;
53. Conduct Disorder 8th March 2004;
54. The role of CST 8th March 2004;
55. the role of the commission 8th March 2004;
56. MedicarePlus Update 15th March 2004;
57. Clinical Risk Management Masterclass 15th March 2004;
58. Wetting and Soiling in Children 15th March 2004;
59. Clinical Guidelines for Management of Overweight and Obesity 15th March 2004;
60. the general practitioner conference and exhibition 15th March 2004;
61. NPS Management of Hypertension Case Study Workshop 22nd March 2004;
62. Diabetes Education 22nd March 2004;
63. NPS Musculoskeletal Pain Case Study Workshop 29th March 2004;
64. 'Sources for quick, quality answers to clinical questions' 5 April 2004;
65. Managing Cultural Diversity in Mental Health 19 April 2004;
66. GPs Self-Study Module on ME/CFS 19 April 2004;
67. Education Course in Sexual Health 19 April 2004;
68. Immunisation Unravelled 3 May 2004;
69. Being a Doc for a Doc 3 May 2004;
70. “Catastrophic Brain Injury” 17 May 2004;
71. General Practice IT Forum 17 May 2004;
72. Selecting Therapies for Antipsychotic Response Review Program 31 May 2004;
73. Level 1 Familiarisation Training via CD ROM 7 June 2004;
74. Palliative Care for Indigenous People - Satellite Broadcast 7 June 2004;
75. Hepatitis C Update for Medical Practitioners 28 June 2004;
76. Education Course in Hepatitis C 28 June 2004;
77. Education Course in HIV Medicine 28 June 2004.
Provide education for practice staff on topics such as developing and maintaining patient registers, developing and maintaining reminder/recall systems, increasing immunisation rates (data cleansing), new schedules, cold chain management, accreditation, PIP and other topics of clinical relevance Number of education opportunities provided to practice staff
Evidence of services provided		 56 to date

1. HIC Online 7th July 2003;
2. AMAQ PD for Practice Managers 7th July 2003;
3. Patient Scheduling 7th July 2003;
4. Medicare Claiming 7th July 2003;
5. RCNA Education Expo 21st July 2003;
6. Preventing Medication Errors 21st July 2003;
7. Basic Care of the Elderly 21st July 2003;
8. Basic Care of Sick Children 21st July 2003;
9. Business Advantage 21st July 2003;
10. Unfair Dismissal 28th Jul 2003;
11. MS Excel Training 21st July 2003;
12. MS PowerPoint Training 21st July 2003;
13. Medical Terminology 21st July 2003;
14. Practice Nurse Network SCOPE 11 August 2003;
15. Wound Care 18th August 2003;
16. Communicating with Difficult Patients 18th August 2003;
17. Vaccinations 18th August 2003;
18. Insulin Pumps 18th August 2003;
19. Basic Care of a Person with Dementia 25th August 2003;
20. Elderley Patients Conference 25th August 2003;
21. Aged Care Management Conference 25th August 2003;
22. Acting Nurse Managers Seminar 25th August 2003;
23. Practice Nurse Conference 25th August 2003;
24. Patient Service Skills 29th September 2003;
25. First Aid 29th Sept 2003;
26. IT 29th Sept 2003;
27. Negotiation and Conflict Management 29th September 2003;
28. Nurses Award 29th September 2003;
29. Responding to Aggression 6th Oct 2003;
30. Dementia Introduction 6th Oct 2003;
31. Aboriginal & Torres Strait Islander Cultural Awareness 6th October 2003;
32. Introduction to Research 6th Oct 2003
33. Communicating with Difficult Patients 13th October 2003;
34. Immunisation Workshop 3rd November 2003;
35. Certificate III in Business: Medical Reception and Health Care Practice Administration 3rd November 2003; 35. Diploma of Practice Management 3rd November 2003
36. Diabetes Update 3rd November 2003
37. First Aid Training 24th Nov 2003
38. Aged Care- Not a Trivial Pursuit 8th Dec 2004
39. Breastfeeding mothers 26th January 2004;
40. Practice Managers Network Meeting 26th January 2004;
41. Computer protection 2nd February 2004;
42. AMAQ Practice Manager Training: patient scheduling 2nd February 2004;
43. Time Management 2nd February 2004;
44. First Aid Training 2nd February 2004;
45. Managing Anger: A Seminar for Nurses 9th February 2004;
46. The Future belongs to the Competent: A Workshop for Nurses 9th February 2004;
47. Nursing and the management of conflict 9th February 2004;
48. People Skills 1st March 2004;
49. GPBA Risk Management 8th March 2004;
50. Practice Infection Control 15th March 2004;
51. AAPM Staff Development Day 15th March 2004;
52. Royal College of Nursing Lifelong Learning Program 15th March 2004;
53. ECG Made Easy 15th March 2004;
54. Oncology Care Workshop 22nd March 2004;
55. Diabetes Education 22nd March 2004;
56. Hospital to Home Conference for Nurses 22nd March 2004;
57. The Role of the Practice Nurse in General Practice 29 March 2004;
58. Mind, Body and Soul in Oncology Care 29 March 2004;
59. MHRT - Mental Health Review Tribunal - Forum 29 March 2004;
60. AAPM Staff Development Day 29 March 2004;
61. Royal College of Nursing Life Long Learning Program 29 March 2004;
62. MedicarePlus: What it means for practice nurses 5 April 2004;
63. Computer Skills 5 April 2004;
64. Immunisation Data Management 5 April 2004;
65. Basic Care of the Elderly 5 April 2004;
66. Working within a Team 5 April 2004;
67. “Divorce and Separation Recovery Workshop” 9 April 2004;
68. Immunisation Unravelled 3 May 2004;
69. First Aid for Medical Receptionists 10 May 2004;
70. Patient Scheduling 10 May 2004;
71. Medical Reception Skills 10 May 2004;
72. First Aid & Resuscitation Course 10 May 2004;
73. General Practice IT Forum 17 May 2004;
74. Postgraduate Certificate in Women Centred Clinical Care 7 June 2004;
75. Pap Test Training for Nurses 7 June 2004;
76. Dealing with Difficult People 7 June 2004
Maintain Self Assessment Scheme status with RACGP 100% of education activities awarded RACGP CPD points 100% (15 sessions, 5 of which were 5 pph activities) of education activities awarded RACGP CPD points

14/8/2003 GP Business Advantage - Module 8 (2pph)
02/12/03 NPS Case Study “Managing a Drinking Problem” (2pph)
10/02/04 Aged Care: Not a Trivial Pursuit (5pph)
25/02/04 NPS Case Study “HRT” (2pph)
17/03/04 NPS Case Study “Analgesics in Musculoskeletal Pain” (2pph)
20/03/04 “A Doctor's Bag for the Dying” (5pph)
06/04/04 Obs & Gynae THS Combined Education Night (2pph)
27/04/04 NPS Case Study 'Hypertension' (2pph)
4/05/04 Rural Roadshow Gatton (2pph)
6/05/04 Rural Roadshow Oakey (2pph)
8/05/04 Mental Health Level 2 Training (5pph)
12/05/04 Immunisation Unravelled (2pph)
25/05/04 Rural Roadshow Pittsworth (2pph)
1/06/04 Mental Health Level 2 Training (5pph)
22/06/04 Mental Health Level 2 Training (5pph)
Contract GPs and practice staff to write articles for Division Newsletter on matters that impact on general practice At least 1 article written by GPs per edition of Division Newsletter July 2003: 7 articles by GPs
October 2003: 2 articles by GPs
December 2003 5 articles by GPs
March 2004 3 articles by GPs
May 2004 2 articles by GPs

July 2003 : Dr Murray Pietsch article re: MAHS Program; Dr Andrew Cumming article re: Toowoomba Health Service District Directory of Services; Dr Shirley Chapman article re: Home Medication Review Education Evening; Dr Robert Craig article re: Integrate for Recovery Mental Health Program; Dr Bevan Kindt article re: Diversity of General Practice (WSRGP); Dr Nina Machin article re: Emergency Medicine (WSRGP); Dr Pat Gooch article re: Literacy Care Australia
October 2003: Dr Heather Fogerty article re: Depression - What is the Latest?; Dr John Lamb Article re: Leadership Weekend December 2003: 'GP Connections unites with Service Providers to bring Toowoomba the Patient Health Passport' Dr John Lamb; SEAM Update Dr Hume Rendle-Short; Leadership Weekend Report Dr Shirley Chapman; Working Together for Better Mental Health Outcomes Dr Robert Craig; Community Connections Dr Robert Craig; March 2004 Aged Care: Not a Trivial Pursuit Dr Judy Egerton, Dr Kate Craft, Dr Dilip Dhupelia, Dr John Lamb, Dr Rob Greenhill; Breastfeeding with Dr Wendy Brodribb; Dealing with Difficult Patients with Dr Graham Emblen ; May 2004 Aged Care: Not a Trivial Pursuit Case Study with answers, Dr Robert Craig, 10 years of Divisions Dr John Lamb.
Update GPs on issues impacting on general practice via monthly Newsletters, weekly/fortnightly fax-stream containing relevant “Snippets” of information, Division brochure, Division website Monthly newsletter distributed to GPs/Practices and other key stakeholders

Weekly fax streams to GPs/Practice Staff		 Newsletter distributed in July 2003; October 2003; December 2003; March 2004 ; May 2004



44 editions of GP Snippets from 2003-2004
40 editions of PS Snippets to date from 2003-2004

Snippets distributed : 7th July 2003; 14th July 2003; 21st July 2003; 4th August 2003; 11th August 2003; 18th August 2003; 25th August 2003; 1st September 2003; 8th September 2003; 15th September 2003; 22nd September 2003; 29th September 2003; 6th October 2003; 13th October 2003; 27th October 2003; 3rd November 2003; 17th November 2003; 24th November 2003; 1st December 2003; 8th December 2003; 15th December 2003; 22nd December 2003; 26th January 2004; 2nd February 2004; 9th February 2004; 16th February 2004; 1st March 2004; 8th March 2004; 15th March 2004; 22nd March 2004; 29 March 2004; 5 April 2004, 12 April 2004; 19 April 2004; 26 April 2004; 3 May 2004; 10 May 2004; 17 May 2004; 31 May 2004; 7 June 2004; 14 June 2004; 21 June 2004; 28 June 2004
Disseminate condensed information to GPs, when appropriate, on issues that impact directly on general practice 100% of GP members receive information about issues impacting on general practice 100% of GP members receive information about issues impacting on general practice
GP Board members to meet with each practice to assist them in three ways:
1. Understanding of the role that the Division plays in building practice capacity
2. Determining GP needs
3. Considering member suggestions on ways forward for General Practice and the Division		 At a minimum, each practice should have contact with at least one GP Board member over the period of a year 14 Practices visited from 2003 -2004

Practice vists to Drs Hudson, Bilbrough, Macdermott, Fogerty, Sklavos, Gillmore, Dhaniram, Domrow, Juhasz, Stuart, Dahl, Peters, Greenhill, Carroll
Assist General Practice in maximising the use of Practice Nurses eg providing details on how practices can afford to place a nurse in their practice via the use of tools such as Financial Modelling.
(CDM (Capacity Building & Linkages))		 Evidence of activities to increase the role of practice nurses Resource Officers utilise opportunistic means to encourage uptake of practice nurses within general practice
Maintain the “Practice Staff Support Network” through the facilitation of regular meetings of practice managers, practice nurses and other practice staff (separately or as an entire group).
(CDM (Capacity Building & Linkages))		 Evidence of collaborative activities with health care organisations and relevant community groups 8 Practice Nurse Meetings hosted 2003- 2004

15th August 2003 SCOPE - Shared Care Outreach Program (THS) 10 Practice Nurses in attendance
17th September 2003 Wound Care 12 Practice Nurses in attendance
21st October 2003 Dealing with Difficult Patients (Dr Graham Emblen) 7 Practice Nurses in attendance
20th November 2003 Immunisation (DDPHU & VIVAS) Workshop 42 Practice Nurses & Staff in attendance
24th November 2003 Diabetes Update 25 Practice Nurses in attendance
17 February 2004 Breastfeeding
(with Dr Wendy Brodribb) 12 PNs in attendance
18 March 2004 ECGs Made Easy
(with Anthony Wollaston)
31 PNs in attendance
18 May 2004 - Accreditation is Good
(with AGPAL)
14 PNs in attendance
Promote and provide appropriate access to CPD and QA and to other relevant educational opportunities.
(CDM (Professional Development & Quality Assurance))		 Number of key CDM related CPD, quality improvement and clinical audit sessions offered 2 CDM related CPD, quality improvement and clinical audit sessions offered during the reporting period

24th November 2003 Diabetes Update

ACR Workshop (Gatton) (21/10/2003)
Provide education to practice staff on such topics as developing and maintaining patient registers, developing and maintaining reminder/recall systems and other topics relating to CDM.
(CDM (Education, Training & Support))		 Evidence of services provided (including uptake of SIP and Outcomes payments) Employment of 3 Practice Nurse Resource Officers and 1 Practice Support Officer

Ongoing training provided through Practice Nurse Resource Officers and Practice Support Officers
Develop Educational Resource Materials that may be utilised in small or large group settings and on the web (Urban, Rural and Remote).
(CDM (Education, Training & Support))
Identify and provide appropriate education, information and training needs of GPs, practice staff and other relevant health service providers regarding Chronic Disease Management.
(CDM (Education, Training & Support))
Assist general practice in the effective management of information.
(CDM (Information Management & Support Systems))		 Percentage of practices using electronic
ø Register/recall systems
ø Patient databases
ø Prescribing
ø Data retrieval/analysis
ø Practice management systems		 Baseline data collected

Specific figures unable to be accessed at time of reporting
Demonstrate the advantages and benefits that Information Management (IM) brings to clinical work and management of the practice.
(CDM (Information Management & Support Systems))		 Number of practices accessing IM Module for practice implementation
Evidence that practices have increased their capacity to manage IM		 3 practices have completed the individual workshop
Identify and support GPs who are registered under the Better Outcomes in Mental Health Care Initiative incentive payment to refer people with a mental disorder to allied health services for specific time limited treatment, as part of the 3 Step mental Health Process.
(Integrate for Recovery)		 See attached “Integrate for Recovery” report
Evaluate the “Assess to Allied Mental Health Services Program” on a local scale and contribute to the national evaluation of the whole Better Outcomes in Mental Health Care Initiative.
(Integrate for Recovery)		 See attached “Integrate for Recovery” report
Conduct a professional development program for GPs on the Quality Use of Medicine with appropriate Clinical Audit and Case Study Meetings (link with CDM when appropriate)
(NPS)		 See attached “NPS” report
Streamline the process of HMR for GPs and Patients (HMR) See attached “HMR” report
Conduct education for patients and family members
(SEAM Palliative Care) 		See attached “SEAM” report
Conduct and provide access to education sessions for GPs (Palliative Care – SEAM & Dr's Bag for the Dying)) See attached “SEAM” and “Doctors' Bag For The Dying” reports
Develop Educational Resource Materials that may be utilised in small or large group settings and on the web (Urban, Rural and Remote) – (SEAM & Drs Bag for the Dying- Palliative Care, See attached “SEAM” and “Doctors' Bag For The Dying” reports


ProgramBUILDING CAPACITY IN GENERAL PRACTICE
GoalTo improve and sustain the quality and efficiency of general practice
StrategyBuild a primary care workforce that meets the need and expectations of its community
OutcomesActivitiesIndicatorsResults&Commentary
Increased stability, capacity and satisfaction of the general practice workforce Evaluate currently available Dr's Health Programs eg QRMSA; Dr Graham Emblen Options paper tabled at Board Meeting by June 2004 Dr Dilip Dhupelia appointed GP Resource person, Nick Pascual appointed Program Coordinato

Doctor's Health Workshop 10th June 2004
Feature individual GP Profiles, in the Division Newsletter, that highlight areas such as their concerns, interests and suggested ways forward for general practice and the Division 1 GP profile per edition 1 GP Profile per edition

July 2003: GP Profile of Dr John Lamb
October 2003: GP Profile of Dr Robert Rimmer
December 2003: GP Profile of Dr David Reid;
March 2004: GP Profile of Dr Carol Cox;
Emphasise, through regular press releases, the important role that general practice plays in the delivery of primary care Number of press releases issued annually 6 media releases in 2003- 2004

25/7/2003 Family Doctor Week 2003
3/9/2003 GP Connections AGM 2003
4/9/2003 GP Connections elects new leader
18/11/2003 Medicare Plus: A step in the right direction
15/12/2003 GP Connections launches Patient Health Passport
19/04/2004 Workforce Crisis “GPs ask for public patience”
Engage Practice Nurses in the Activities of the Division when appropriate.
(CDM (Capacity Building & Linkages))		 Continue to engage services of Practice Nurse Resource Officers 3 practice nurse resource officers engaged.

Provide assistance to rural practices in employing locums and /or relief practice staff
(WSRGP) 		Options paper tabled at Board meeting by February 2004

Needs analysis conducted by November 2003

Planned for 2004 - 2005



Needs analysis was delayed to next reporting period due to the unusually high number of surveys already being sent to practices at the time the survey was to be sent.
Provide an orientation program for GP Registrars and medical students new to the Division
(WSRGP) 		2 orientation programs conducted per year 5 orientation programs conducted in 2003-2004

Medical Students lunches:
18/11/2003, 18/10/2003, 26/8/2003, 15/7/2003, 13/04/2004
Registrars:
Early 2004
Provide free Division membership with attendant benefits to registrars and medical students while in the Division
(WSRGP) 		100% of registrars and medical students invited to become members of the Division 100% of registrars and medical students approved for Division Membership
(10 in the reporting period)

July 2003: 1 Registrar
Sept 2003: 1 Registrar
Dec 2003: 1 Registrar
Jan 2004: 7 Registrars
Proactively encourage registrars to participate in Division CPDs
(WSRGP) 		Increased number of medical students and registrars attending Division CPDs 5 registrars attended CPD activities

RACGP Eye Skills Workshop - 1/11/2003 - 2 registrars attended
Aged Care: Not a Trivial Pursuit February 2004 - 3 registrars attended
Provide networking opportunities for rural GPs (WSRGP) Conduct at least three rural network gatherings during the year 3 network meetings completed

4th, 6th, 26th May 2004 - Rural Roadshows conducted in Gatton, Oakey and Pittsworth respectively. Each evening involved all GPs in the area, all practice staff and local pharmacists. An overview of the Division, an NPS Case Study and the opportunity to network.
Appoint a Specialist Oncology Nurse to position of Palliative Care Liaison Nurse
(SEAM Palliative Care)		 See attached “SEAM” report
Facilitate the collaboration of the SEAM Nurse with the GP to care for the Palliative Care Patients (SEAM Palliative Care) See attached “SEAM” report
Support the SEAM Nurse in assisting GPs to explore the role of Practice Nurse in Case Management
(SEAM Palliative Care)		 See attached “SEAM” report
Contract a clinical pharmacist to conduct clinical detailing
(NPS)		 See attached “NPS” report


ProgramCONTINUUM OF CARE
GoalTo develop key partnerships and alliances that assist general practice to strengthen the primary care sector
StrategyWork with hospital to develop integrated models of care
OutcomesActivitiesIndicatorsResults&Commentary
Relationships & links between hospitals & General Practice are improved, resulting in holistic strategies & outcomes, which facilitate a 'seamless system of care' Determine strategic priorities for the TDDGP / THS Collaborative through meetings of the "Building Better Partnerships" committee (a con-joint committee of executive representatives from TDDGP and Toowoomba Health Services (THS) Evidence of progressive achievements in MoU priorities with THS 1. SCOPE and Palliative Care maintained and built upon throughout 2003-2004. GPC has commented numerous times on the provision and future of SCOPE. The SEAM service works closely with the Palliative Care Liaison Nurse at THS ensuring streamlining of palliative services in the community
2. GPC has worked closely with THS in the development of a new model of GP Liaison that focuses the goals on addressing the continuity of care framework. This is based on findings from interviews conducted with former GPLOs Dr Robert Craig and Dr Shirley Chapman. The new model will be conducted throughout 2004-2005
3. GPC has endeavoured to streamline all communication with THS. Specifically, THS receives Snippets each week and GPC receives all media releases and an electronic copy of the THS newsletter. GPC has worked closely with THS on the development of admitting and discharge processes through the TrACC Committee. A copy of the THS service directory is now available on the GPC website and has been forwarded to GPs for instalment on their desktops.
4. During 2003-2004, GPC renewed the agreement with the Mental Health Services to refer to the MIRT service - an integrated model of mental health care. GPC continue to work with THS in the development of other integrated models of care
5. Specifically GPC has representation on the Step Down Project Group addressing the need for step down services in the district. Consumer representation was drawn from the local TRUST group with the president of this aged and disability service contributing valuably to the proceedings.
6. GPC continues membership on the continuum of Care Committee with THS ensuring GP issues are always addressed in the design and development of processes at a hospital level.
7. GPC is working closely with THS in the newly flagged GP Clinics model addressing the after hour needs of the Toowoomba region

1. Maintain current programs such as SCOPE and Palliative as well as continue to explore future collaborative opportunities.
2. Further establish the GP Liaison Officer position within the Toowoomba Health Service District. The duties attached to this position include appropriate representation on Management and Clinical Care Committees.
3. To explore methods of improving communications using available technology such as e-mail, web pages, newsgroups, facsimile or other relevant methods.
4. Explore options for developing integrated Obstetric, Diabetes, Mental Health and Asthma models of care.
5. Seek consumer representation on appropriate program work groups.
6. Further develop the linkages through the Continuum of Care Committee
Develop options for the provision of after hours health care services in the primary care setting
Continue to half-fund GP Liaison Officer position at THS Evidence of issues actioned 7 GP Liaison Meeting held
GP Liaison Officer resigned December 2003. This position has been revised

GP Liaison Meetings 23rd July 2003
27th August 2003 attended by Dr Hume Rendle-Short & Dr Shirley Chapman Issues actioned: Paragraph of information inserted into GP Newsletter advising that as much information as possible to be given when referring to ATODS.
24th September 2003 Issues actioned: G P Liaison officer advised GP's that referral form available on web site; GP list of contact details and availability is updated every 3 months. This information is available on disc. This list can be circulated within the Hospital but not to be given. GP Connections has supplied this information to THS; THS to co-sponsor educational events planned and publicised through GP Connections, events have been planned for 2004; Information regarding TRACC and SCOPE included in weekly Snippets
23rd October 2003 Issues Actioned: GPLO has contacted the Endoscopy Unit regarding the open referral system. Endoscopy is not a true open-ended referral system but fast tracking. Triage Doctor may send patient directly to Endoscopy rather than through Medical Outpatients. GPLO commented that the Specialist Referral Form was not user friendly. Committee Member advised the Mater Hospital have a referral form (G P designed) which is being used increasingly and will be offered to Queensland Health in the near future. It was decided to wait three months before reviewing the Specialist Referral Form
5th February 2004 Issues Actioned: Calendar finalised. Obs & Gynae Education Night planned 24th March 2004: Discussion was held as to what the Toowoomba Health Service and the Division of General Practitioners want in regard to this position.

Toowoomba Health Service:-
ø Health Services want GP input into decision making process. Liaison Officer needs to be practising GP and yet be involved in what is happening in the Health Service.
ø GP database/spreadsheet was huge project
ø No key support role for G P Liaison Officer (ie admin support)
ø Position was set up to fail
ø It is vital to have the position filled to bridge G P services with Hospital services but also has to bridge state to commonwealth.
ø Position could be filled by retired GP who has no operational issues to consider.
ø Toowoomba Health Service bound by Queensland Health guidelines.

Huge projects happening which are linked with G P's ie Renal Services Plan, Diabetes model of service delivery and the Commonwealth Cancer Care Plan. Division of General Practitioners:-
Dr Hume Rendle Short attended ISAP workshop and felt the move was from Queensland Hospitals to the Health of Queenslanders
Division does not believe they received value for money but had learning process.
Believes there is sufficient work for two full time GP's
GPLO funded by Health Service - query value for money.
28 April 2004: The education evening held in April was excellent. Because of positive feedback more GP's will probably attend the next evening.
Dr Hume Rendle Short has not approached the Division of GP's Board but would like to see Community TRACC nurse and GP practice nurse swap roles for a period of time ie work exchange. Worth exploring - could be complications
Two practices would be willing to have Nurse exchange.
Available as PDF file and will be updated again in June 2004.
File to be sent to Division of G P's for their secured area on their website. This has not been developed yet.
Request Anne Pyke to send updated version to Sam at G P Connections so she can forward to GP's to put on their PCs Discussion was held with regard to the relevance of this meeting and the Building Better Partnerships meeting.
GP Liaison Committee is the operational Implementation committee whilst Building Better Partnerships is the strategic issues committee.
As the G P Liaison officer position is vacant, the committee decided to meet quarterly on the Wednesday after the Building Better Partnerships Committee.
Other issues could be discussed on an as needs basis
Sam Fitzgerald from G P Connections and Glenys Cockfield Acting Chair of the Committee would meet on a monthly basis to progress any issues.
Investigate the possibility of employing a Program Officer to assist the GP Liaison Officer in his/her role Discussion paper tabled at Board meeting by December 2003 Model of support is finalised and will be launched in 2004 -2005
Continue involvement in shared care programs with THS eg Diabetes, Obstetrics Evidence of effective partnerships with other service providers through various shared care arrangements Shared care for Obstetrics and Gynaecology continues

Discussions are continuing in other areas such as: ATODs, Emergency Department and Mental Health Services. GPC sits on the Antenatal Integrated Model of Care Project Team.
Develop strategic alliances between relevant Hospitals and General Practice Evidence of issues actioned GP Connections continues to negotiate closer links between St Andrew's Hospital, St Vincent's Hospital and General Practice

Currently progressing issues with St Andrew's to improve communications between GPs and Specialists
Implement an electronic GP Register eg GP Links (to determine GP availability in accepting new public hospital patients) “GP Register” updated quarterly with Toowoomba Health Services Database updated four times in 2003-2004

Nick Pacual and Hume Rendle-Short met with THS and GPLO to discuss this issue. The GP database (note - refer to it now as a spreadsheet), will be implemented at THS and will be linked to the front page of their intranet. Updates to be sent on a quarterly basis or sooner if required
Promote and support Division participation in relevant committees eg THS, St Andrews and St Vincent's Hospitals, DDPHU, regional GP training, local community health, local government health Evidence of effective links GP Connections has representatives on 5 committees

Dr Peter Skalavos attended the Medical Advisory Committee, St Vincent's Hospital on 9 Oct 03 Points raised:
(a) No psychiatric cases can be admitted to SVH
(b) children under 18yrs cannot be admitted to High Dependency
(c) Orthopaedic Case Manager interviews are being conducted
(d) Failings of Medical Director drug summary lists
(e) complaint about admissions from outside Toowoomba
(f) maternity lights subject to electrical engineering quotations
Facilitate general practice linkages with Specialists, Allied Health Professionals and Toowoomba Health Service. (CDM (Capacity Building & linkages)) Evidence of effective links 5 events held throughout the reporting period that involved attendance of GPs, Specialists and Practice Nurses

02/12/03 NPS Case Study “Managing a Drinking Problem”
(Specialist: Dr Steve Cramb from THS ATODS)
15th August 2003 SCOPE - Shared Care Outreach Program (THS) 10 Practice Nurses in attendance (with THS Staff from SCOPE presenting)
17th September 2003 Wound Care 12 Practice Nurses in attendance (With THS nurses presenting)
20th November 2003 Immunisation (DDPHU & VIVAS) Workshop 42 Practice Nurses & Staff in attendance (with presenters from THS, DDPHU and HIC)
24th November 2003 Diabetes Update 25 Practice Nurses in attendance (with THS involvement)
25/02/04 NPS Case Study “HRT” (2pph) (specialists, pharmacists and allied health)
17/03/04 NPS Case Study “Analgesics in Musculoskeletal Pain” (2pph) (specialists, pharmacists and allied health)
06/04/04 Obs & Gynae THS Combined Education Night (2pph) (allied health & hospital staff)
27/04/04 NPS Case Study 'Hypertension' (2pph) (specialists, pharmacists and allied health)
4/05/04 Rural Roadshow Gatton (2pph) (specialists, pharmacists and allied health)
6/05/04 Rural Roadshow Oakey (2pph) (specialists, pharmacists and allied health)
8/05/04 Mental Health Level 2 Training (5pph) (allied health)
12/05/04 Immunisation Unravelled (2pph) (specialists, pharmacists and allied health)
25/05/04 Rural Roadshow Pittsworth (2pph) (specialists, pharmacists and allied health)
1/06/04 Mental Health Level 2 Training (5pph) (allied health)
22/06/04 Mental Health Level 2 Training (5pph)
17 February 2004 Breastfeeding
(with Dr Wendy Brodribb) 12 PNs in attendance (other nursing staff)
18 March 2004 ECGs Made Easy
(with Anthony Wollaston)
31 PNs in attendance (THS and nursing staff)
18 May 2004 - Accreditation is Good
(with AGPAL)
14 PNs in attendance (nursing staff)
Inform General Practice as to changes in the Public Hospital system eg: changes in processes for referring / discharge.
(CDM (Capacity Building & linkages))		 Evidence of referral, communication protocols developed or updated GPC consistently liaises with THS to improve communication systems. This progress is ongoing

1. Monday 8th September 2003 Brodribb / RSL In-home Rehabilitation Support Services Sub-Committee Meeting
ø Brochure designed and developed for dissemination within the Hospital by Sam Fitzgerald Attendees: RSL Brodribb THS GP Connections Carelink

2. Thursday 11th September 2003 Brodribb / RSL in-home rehabilitation Support Services Steering Committee meeting
ø Brochure disseminated, changes to be made by Sam
ø Sam to source GP for committee GP sourced 17th Sept 2003 - Dr Michael McDonnell Attendees: RSL THS GP Connections Carelink DoHA HACC

3. Thursday 11th September 2003 Health Passport Þ Sam to ring Peter Nolan
ø Set up meeting to put together health passports if sufficient funding
ø If not, arrange meeting with Action Group & DoHA Attendees: Robina Canning Sam Fitzgerald

4. Monday 15th September 2003 Carelink & GP Connections proposal for Aged Care education evening for GPs and Practice Staff Design 5 pph CPD Aged Care Educational Activity
ø PBL
ø Utilise specialists eg. Peter Nolan, Eddie Tan @ the Empire Theatre Studio Room, light supper, coffee & tea
ø Proposed 2nd Dec 2003
ø Next meeting scheduled Wed 1st Oct 2003 2pm Attendees: Sam Fitzgerald Linda Fitzgerald Wendy Holt

5. Monday 15th September 2003 Aged Care Health Passport Aged Care Education Activity
ø Dr Nolan has sought funding from Hospital Foundation Þ Sam to design survey to go in passport
ø Aged Care Monopoly: Dr Nolan's suggestion for structure
ø Contact Dr Paul Dalgleish, Director of Geriatrics at Princess Alexandra Hospital to be a presenter at Education night
ø Dr Nolan to forward information to SamÞ Sam to schedule meeting upon receipt of information Attendees: Sam Fitzgerald Dr Peter Nolan

6. Monday 22nd September 2003 IRSS @ Brodribb
ø Develop flowchart
ø Develop Selection Criteria formsÞ Tweak brochure
ø Develop Referral Form for THS usage Sam Fitzgerald Pam Chipperfield Carole MacGowan

7. 25th September 2003 Brodribb & RSL Committee Meeting Forms finalised and presented Attendees: RSL THS GP Connections Carelink DoHA HACC

8. Wednesday 1st October GP Connections & Commonwealth Carelink Discussion regarding Aged Care: Not a Trivial Pursuit; selected quizmasters: Dr Peter Nolan, Dr Robert Craig, Dr Eddie Tan and Dr Hume Rendle-Short Attendees: Sam Fitzgerald & Wendy Holt.

9. Thursday 23rd October 2003 IRSS Brodribb & RSL Committee Meeting Attendees: Kelvin Lindbeck, Chris Clark, Carole Macgowan, Pam Chipperfield Glenys Cockfield, Dr McDonald, Marion Worrall Actions: Brochure IRSS - Flowchart Fact Sheet Client not responding to Rehab on program Statistics 11.09.07 Patient Information Brochure 11.09.13 Training/Resource Development 09.10.01 Treatment of Clients on existing Care programs.

10. Friday 7th November 2003 OPIG Meeting Attendees: Robina Canning (Blue Care/ St Andrews Community Liaison), Di McLoughlin ( Area HACC Manager), John Leopold ( Manager Community Health THSD), Chris Clarke ( CACPS Coordinator Brodribb Home), Maureen Parker ( Sisters of Charity Outreach Centre), Kaye Doherty ( Fairhaven Care Centre), Malea Cudlipp ( Fairhaven Care Centre) , Leigh Bailey ( Community Development Officer Carers Qld), Mick Burge ( Consumer Advocate TDMHS), Lyndall Chambers ( Dept of Veterans Affairs), Michelle Crawford ( SEAM nurse GP Connections), Karen Brosnan ( Director of Care Service Toowoomba Hospice), Carole McGowan ( Community Care Coordinator RSL Care), Eddie Tan ( TDMHS), Megan Owen (ACAT), Irene Lincoln (TRUST), Sam Fitzgerald (GP Connections) , Dawn Batts ( Commonwealth Carelink Centre DDSWQ), Wendy Holt (Commonwealth Carelink Centre DDSWQ) Actions: Responsibilities of Chair and Minute Taker to be rotated with Minute Taker from one meeting becoming Chair at next meeting. From February, meetings will be held 3 monthly on the 1st Friday of the month commencing at 8.30am. Those present were asked to identify their interest by notation on the attendance register. Other members who are interested in contributing to this project may obtain further information from Dawn Batts d.batts@bluecare.org.au All service providers are encouraged to visit the new Toowoomba office. Carers Qld also has an extensive library and resources for carers. Copies of Mental Health video and/or further information is available from Michael Burge Consumer Consultant Toowoomba District Mental Health Service. Presentation by SEAM Nurse about the SEAM service operated through GP Connections - contact details given. The Toowoomba Hospice has a small meeting room which is available to service providers and groups. Inquiries are welcome. Seniors Expo -This idea was raised at the first meeting of the Older Persons Interest Group and is now ready to be given further consideration. A small group of people indicated their willingness to form a planning committee for this event. The focus will not be on the issues of growing older, but on the positive aspects of our golden years. Possible theme to be either ' Preparing not to give life up, but to live life up' or 'Don't give up- live up'. A suggestion has been received that it be labelled a 'Happy Ageing Seniors Expo'

11. Wednesday 12th November 2003 Aged Care Patient Health Passport Attendees: Sam Fitzgerald, Robina Canning Action: Initiate self- funding through collaboration, Sam to write letters to relevant service providers seeking funds.

12. Friday 14th November 2003 Meeting for Aged Care: Not a Trivial Pursuit with Commonwealth Carelink Centre Attendees: Sam Fitzgerald Wendy Holt Dawn Batts. Actions: Date changed to 10th February 2003, Meetings with Quizmasters and Service Providers scheduled, venue booked, pies to be made.

13. Monday 17th November 2003 Patient Health Passport Attendees: Sam Fitzgerald Robina Canning Actions: Letter written and disseminated, funding forthcoming from Dr Peter Nolan, presentation for Queensland Aged Care Conference finalised, Sam designated Project Coordinator for Patient Health Passport.

14. 18th December 2003 Patient Health Passport Meeting to put them together Attendees: Dr Peter Nolan THS, Robina Canning Bluecare; Dawn Batts Commonwealth Carelink Centre; Wendy Holt Commonwealth Carelink Centre; Lois Gotz Nu Mylo; Sue Geiszler OzCare; Sam Fitzgerald GP Connections.

15. 18th December 2003: GP Connections requested by ADGP to comment on MedicarePlus Aged Care initiative by the 14th January 2004. Focus Group planned for Wednesday 7th January 2004.

16. 7th January 2004 Focus Group to provide feedback on the MedicarePlus Aged Care Initiative as requested by ADGP for their submission to the Australian Government Attendees:
ø Dr Hume Rendle-Short - Chairperson
ø Sam Fitzgerald - GP Connections representative
ø Kerry Thorpe - Practice Nurse
ø Dr Robert Craig - GP
ø Dr Pat Stuart - GP
ø Cynthia Woltmann - Director of Nursing
ø Tricare Charmaine - Nurse
ø Maxine Noone - Lourdes Home
ø Pam Chipperfield - DoN Brodribb Home
ø Carole McGowan - DoN RSL Care
ø Dr Tim Reye - GP
ø Dr Pat Gooch - GP

17. Friday 9th January 2004 Meeting with ACAT from THS Discussed sharing pilot information so as to collaborate on the patient held record project when funding becomes available either through QLD Health or other means Sam Fitzgerald John Leopold (Director of Community Health) Gail Cope (Director of ACAT)

18. Tuesday 13th January 2004 Finalisation of MedicarePlus Aged Care Initiative Feedback Dr Hume Rendle-Short Sam Fitzgerald

19. Tuesday 20th January 2004 Directions given to Quizmasters to produce case studies Dr Eddie Tan Dr Peter Nolan Dr Robert Craig Wendy Holt Sam Fitzgerald

20. Tuesday 27th January 2004 Instructions given to SPs re: Aged Care: Not a Trivial Pursuit and Case Studies given out Wendy Holt Dawn Batts Robina Canning Julie Palmer DVA Betty Noble OzCare Cheryl Clark OzCare Trish Cole ACAT Sue Geiszler OzCare Jill Cory Christine Simons Lyndell Chambers DVA Older Person's Mental Health Centrelink Public Trustee Alzheimer's Association Carer Respite

21. Wednesday 28th January 2004 Portfolios handed out Venue: Carole McGowan Trade Display: Wendy Holt Finance/Sponsorship: John Leopold Local Entertainment: Chris Clarke Guest Speakers: Lyndell Chambers Food: Robina Canning
Marketing/Promotion: Sam Fitzgerald Carelink, GP Connections, BlueCare, Brodribb Home, Department of Veteran's Affairs

22. Tuesday 3rd February 2004 GP Connections Service Provider and Quizmaster Meeting Finalised 10th February Event Robina Canning Dr Robert Craig Dr Eddie Tan Julie Palmer DVA Dr Peter Nolan
Wendy Holt Betty Noble Cheryl Clark Bernice Wareham Trish Cole Sue Geiszler Jill Cory Christine Simons Lyndell Chambers DVA Carol Lee Centrelink Carole McGowan RSL Home Care Liz Hulin Public Trustee

23. Tuesday 10th February 2004 Aged Care: Not a Trivial Pursuit Educational Evening for GPs and Practice Nurses Sam Fitzgerald Wendy Holt Robina Canning Dr Eddie Tan Dr Robert Craig Julie Palmer DVA Dr Peter Nolan Betty Noble Ozcare Cheryl Clark Bernice Wareham Trish Cole Sue Geiszler Jill Cory Christine Simons Lyndell Chambers DVA Carol Lee Robyn Maker Centrelink Carole McGowan RSL Home Care
Liz Hulin Public Trustee Dr Eddie Tan Dr Janina Machin Dr Kate Craft Dr John Lamb Dr Robin Maffey Dr Rob Greenhill Dr Ro Jolley Janelle Salze PN Dr Izak Bakker Dr Rhonda Greensill Dr Dilip Dhupelia Dr Michael Gordon Sam Turner Registrar Dr Lynne King Kerry Thorpe PN Dr Christine Harget-White Dr Win Smit Dr Leslie Dhaniram Madonna Treschman PN Dr Matthew Hocking Registrar Paula McCubben PN Dr Loretto Wainwright Dr Judy Egerton Margaret Harris Medical Student Anne Beygirlioglu Medical Student Helen Gibbs PN Margaret Windsor PN

24. 23rd February 2004 Aged Care Expo Organising Committee Meeting with Aged Care QLD List of duties to be forwarded to Wendy to pass on to Events Organiser Sam Fitzgerald Wendy Holt Robina Canning Lyndell Chambers Chris Clarke Aged Care QLD Representative

25. 4 March 2004 Fax Number change to be 4616 6150 - Attention: Rehabilitation & Aged Care Unit; Medical Certificate to be added to package
ø To be typed & sent with minutes; Judy advised has had meetings with Physio's & OT's to work out ways of checking out patients who may benefit but who may slip through the gap.
Query re patients on 'Step down' program at Oakey - discussion followed - outcome - as these patients have already come through the Base & are on their 'Rehabilitation' program there was no problem with these folk accessing the IRSS Program subject to their suitability; Evaluation form still needs to be developed using the same IRSS logo.;
Workshop announced for 17-18 March 2004 in Canberra
Chris & Glenys to attend - After discussion with 'Tony' from Canberra who advised that there was no necessity to present a paper.
Chris & Glenys to see if others were experiencing a 'slow start' to program & if there were any ways around this.;
1st April 2004 Pam bought to the attention of the Committee the problems encounter regarding the Referral Process.
Judy explained problem should never happen again, as it had been identified through the hospital system and corrected.
Pam suggested that 3 people be nominated as contact points in the hospital. Gleny's said that she had spoken to Donna Ashby and the problem was rectified.; REHAB Score: With reference to this score, Judy was asked if it was possible to get this Score on Admission and Again on Discharge;

26. 3rd June 2004 Judy Wilson confirmed that the 3 Nominations from TBH for Key Contact personal were accepted. Judy advised that a possible 2 more clients may be suitable. Also Judy Wilson to be transferred to Medical Ward soon, and will advocate the program once she is in Unit; ACAT to assess clients at the level of care on first contact not what is expected after program is completed. Further discussion regarding this problem was had, this may be a continuing problem; Meeting arranged with TRAAC nurses, Allied Health Team, ACAT, Brodribb & RSL to reflect on Discharged Clients


ProgramCONTINUUM OF CARE
GoalTo develop key partnerships and alliances that assist general practice to strengthen the primary care sector
StrategyWork with organisations and other health care providers to develop integrated models of care
OutcomesActivitiesIndicatorsResults&Commentary
Establishment of sustainable, integrated models of quality care Advocate for ongoing improvement of Aged Care in the Toowoomba Region addressing Step down, Day Only Assessment, Patient Held Records and Aged Care Wards Evidence of issues actioned 26 meetings held to date

1. Monday 8th September 2003 Brodribb / RSL In-home Rehabilitation Support Services Sub-Committee Meeting
ø Brochure designed and developed for dissemination within the Hospital by Sam Fitzgerald Attendees: RSL Brodribb THS GP Connections Carelink

2. Thursday 11th September 2003 Brodribb / RSL in-home rehabilitation Support Services Steering Committee meeting
ø Brochure disseminated, changes to be made by Sam
ø Sam to source GP for committee GP sourced 17th Sept 2003 - Dr Michael McDonnell Attendees: RSL THS GP Connections Carelink DoHA HACC

3. Thursday 11th September 2003 Health Passport Þ Sam to ring Peter Nolan
ø Set up meeting to put together health passports if sufficient funding
ø If not, arrange meeting with Action Group & DoHA Attendees: Robina Canning Sam Fitzgerald

4. Monday 15th September 2003 Carelink & GP Connections proposal for Aged Care education evening for GPs and Practice Staff Design 5 pph CPD Aged Care Educational Activity
ø PBL
ø Utilise specialists eg. Peter Nolan, Eddie Tan @ the Empire Theatre Studio Room, light supper, coffee & tea
ø Proposed 2nd Dec 2003
ø Next meeting scheduled Wed 1st Oct 2003 2pm Attendees: Sam Fitzgerald Linda Fitzgerald Wendy Holt

5. Monday 15th September 2003 Aged Care Health Passport Aged Care Education Activity
ø Dr Nolan has sought funding from Hospital Foundation Þ Sam to design survey to go in passport
ø Aged Care Monopoly: Dr Nolan's suggestion for structure
ø Contact Dr Paul Dalgleish, Director of Geriatrics at Princess Alexandra Hospital to be a presenter at Education night
ø Dr Nolan to forward information to SamÞ Sam to schedule meeting upon receipt of information Attendees: Sam Fitzgerald Dr Peter Nolan

6. Monday 22nd September 2003 IRSS @ Brodribb
ø Develop flowchart
ø Develop Selection Criteria formsÞ Tweak brochure
ø Develop Referral Form for THS usage Sam Fitzgerald Pam Chipperfield Carole MacGowan

7. 25th September 2003 Brodribb & RSL Committee Meeting Forms finalised and presented Attendees: RSL THS GP Connections Carelink DoHA HACC

8. Wednesday 1st October GP Connections & Commonwealth Carelink Discussion regarding Aged Care: Not a Trivial Pursuit; selected quizmasters: Dr Peter Nolan, Dr Robert Craig, Dr Eddie Tan and Dr Hume Rendle-Short Attendees: Sam Fitzgerald & Wendy Holt.

9. Thursday 23rd October 2003 IRSS Brodribb & RSL Committee Meeting Attendees: Kelvin Lindbeck, Chris Clark, Carole Macgowan, Pam Chipperfield Glenys Cockfield, Dr McDonald, Marion Worrall Actions: Brochure IRSS - Flowchart Fact Sheet Client not responding to Rehab on program Statistics 11.09.07 Patient Information Brochure 11.09.13 Training/Resource Development 09.10.01 Treatment of Clients on existing Care programs.

10. Friday 7th November 2003 OPIG Meeting Attendees: Robina Canning (Blue Care/ St Andrews Community Liaison), Di McLoughlin ( Area HACC Manager), John Leopold ( Manager Community Health THSD), Chris Clarke ( CACPS Coordinator Brodribb Home), Maureen Parker ( Sisters of Charity Outreach Centre), Kaye Doherty ( Fairhaven Care Centre), Malea Cudlipp ( Fairhaven Care Centre) , Leigh Bailey ( Community Development Officer Carers Qld), Mick Burge ( Consumer Advocate TDMHS), Lyndall Chambers ( Dept of Veterans Affairs), Michelle Crawford ( SEAM nurse GP Connections), Karen Brosnan ( Director of Care Service Toowoomba Hospice), Carole McGowan ( Community Care Coordinator RSL Care), Eddie Tan ( TDMHS), Megan Owen (ACAT), Irene Lincoln (TRUST), Sam Fitzgerald (GP Connections) , Dawn Batts ( Commonwealth Carelink Centre DDSWQ), Wendy Holt (Commonwealth Carelink Centre DDSWQ) Actions: Responsibilities of Chair and Minute Taker to be rotated with Minute Taker from one meeting becoming Chair at next meeting. From February, meetings will be held 3 monthly on the 1st Friday of the month commencing at 8.30am. Those present were asked to identify their interest by notation on the attendance register. Other members who are interested in contributing to this project may obtain further information from Dawn Batts d.batts@bluecare.org.au All service providers are encouraged to visit the new Toowoomba office. Carers Qld also has an extensive library and resources for carers. Copies of Mental Health video and/or further information is available from Michael Burge Consumer Consultant Toowoomba District Mental Health Service. Presentation by SEAM Nurse about the SEAM service operated through GP Connections - contact details given. The Toowoomba Hospice has a small meeting room which is available to service providers and groups. Inquiries are welcome. Seniors Expo -This idea was raised at the first meeting of the Older Persons Interest Group and is now ready to be given further consideration. A small group of people indicated their willingness to form a planning committee for this event. The focus will not be on the issues of growing older, but on the positive aspects of our golden years. Possible theme to be either ' Preparing not to give life up, but to live life up' or 'Don't give up- live up'. A suggestion has been received that it be labelled a 'Happy Ageing Seniors Expo'

11. Wednesday 12th November 2003 Aged Care Patient Health Passport Attendees: Sam Fitzgerald, Robina Canning Action: Initiate self- funding through collaboration, Sam to write letters to relevant service providers seeking funds.

12. Friday 14th November 2003 Meeting for Aged Care: Not a Trivial Pursuit with Commonwealth Carelink Centre Attendees: Sam Fitzgerald Wendy Holt Dawn Batts. Actions: Date changed to 10th February 2003, Meetings with Quizmasters and Service Providers scheduled, venue booked, pies to be made.

13. Monday 17th November 2003 Patient Health Passport Attendees: Sam Fitzgerald Robina Canning Actions: Letter written and disseminated, funding forthcoming from Dr Peter Nolan, presentation for Queensland Aged Care Conference finalised, Sam designated Project Coordinator for Patient Health Passport.

14. 18th December 2003 Patient Health Passport Meeting to put them together Attendees: Dr Peter Nolan THS, Robina Canning Bluecare; Dawn Batts Commonwealth Carelink Centre; Wendy Holt Commonwealth Carelink Centre; Lois Gotz Nu Mylo; Sue Geiszler OzCare; Sam Fitzgerald GP Connections.

15. 18th December 2003: GP Connections requested by ADGP to comment on MedicarePlus Aged Care initiative by the 14th January 2004. Focus Group planned for Wednesday 7th January 2004.

16. 7th January 2004 Focus Group to provide feedback on the MedicarePlus Aged Care Initiative as requested by ADGP for their submission to the Australian Government Attendees:
ø Dr Hume Rendle-Short - Chairperson
ø Sam Fitzgerald - GP Connections representative
ø Kerry Thorpe - Practice Nurse
ø Dr Robert Craig - GP
ø Dr Pat Stuart - GP
ø Cynthia Woltmann - Director of Nursing
ø Tricare Charmaine - Nurse
ø Maxine Noone - Lourdes Home
ø Pam Chipperfield - DoN Brodribb Home
ø Carole McGowan - DoN RSL Care
ø Dr Tim Reye - GP
ø Dr Pat Gooch - GP

17. Friday 9th January 2004 Meeting with ACAT from THS Discussed sharing pilot information so as to collaborate on the patient held record project when funding becomes available either through QLD Health or other means Sam Fitzgerald John Leopold (Director of Community Health) Gail Cope (Director of ACAT)

18. Tuesday 13th January 2004 Finalisation of MedicarePlus Aged Care Initiative Feedback Dr Hume Rendle-Short Sam Fitzgerald

19. Tuesday 20th January 2004 Directions given to Quizmasters to produce case studies Dr Eddie Tan Dr Peter Nolan Dr Robert Craig Wendy Holt Sam Fitzgerald

20. Tuesday 27th January 2004 Instructions given to SPs re: Aged Care: Not a Trivial Pursuit and Case Studies given out Wendy Holt Dawn Batts Robina Canning Julie Palmer DVA Betty Noble OzCare Cheryl Clark OzCare Trish Cole ACAT Sue Geiszler OzCare Jill Cory Christine Simons Lyndell Chambers DVA Older Person's Mental Health Centrelink Public Trustee Alzheimer's Association Carer Respite

21. Wednesday 28th January 2004 Portfolios handed out Venue: Carole McGowan Trade Display: Wendy Holt Finance/Sponsorship: John Leopold Local Entertainment: Chris Clarke Guest Speakers: Lyndell Chambers Food: Robina Canning
Marketing/Promotion: Sam Fitzgerald Carelink, GP Connections, BlueCare, Brodribb Home, Department of Veteran's Affairs

22. Tuesday 3rd February 2004 GP Connections Service Provider and Quizmaster Meeting Finalised 10th February Event Robina Canning Dr Robert Craig Dr Eddie Tan Julie Palmer DVA Dr Peter Nolan
Wendy Holt Betty Noble Cheryl Clark Bernice Wareham Trish Cole Sue Geiszler Jill Cory Christine Simons Lyndell Chambers DVA Carol Lee Centrelink Carole McGowan RSL Home Care Liz Hulin Public Trustee

23. Tuesday 10th February 2004 Aged Care: Not a Trivial Pursuit Educational Evening for GPs and Practice Nurses Sam Fitzgerald Wendy Holt Robina Canning Dr Eddie Tan Dr Robert Craig Julie Palmer DVA Dr Peter Nolan Betty Noble Ozcare Cheryl Clark Bernice Wareham Trish Cole Sue Geiszler Jill Cory Christine Simons Lyndell Chambers DVA Carol Lee Robyn Maker Centrelink Carole McGowan RSL Home Care
Liz Hulin Public Trustee Dr Eddie Tan Dr Janina Machin Dr Kate Craft Dr John Lamb Dr Robin Maffey Dr Rob Greenhill Dr Ro Jolley Janelle Salze PN Dr Izak Bakker Dr Rhonda Greensill Dr Dilip Dhupelia Dr Michael Gordon Sam Turner Registrar Dr Lynne King Kerry Thorpe PN Dr Christine Harget-White Dr Win Smit Dr Leslie Dhaniram Madonna Treschman PN Dr Matthew Hocking Registrar Paula McCubben PN Dr Loretto Wainwright Dr Judy Egerton Margaret Harris Medical Student Anne Beygirlioglu Medical Student Helen Gibbs PN Margaret Windsor PN

24. 23rd February 2004 Aged Care Expo Organising Committee Meeting with Aged Care QLD List of duties to be forwarded to Wendy to pass on to Events Organiser Sam Fitzgerald Wendy Holt Robina Canning Lyndell Chambers Chris Clarke Aged Care QLD Representative

25. 4 March 2004 Fax Number change to be 4616 6150 - Attention: Rehabilitation & Aged Care Unit; Medical Certificate to be added to package
ø To be typed & sent with minutes; Judy advised has had meetings with Physio's & OT's to work out ways of checking out patients who may benefit but who may slip through the gap.
Query re patients on 'Step down' program at Oakey - discussion followed - outcome - as these patients have already come through the Base & are on their 'Rehabilitation' program there was no problem with these folk accessing the IRSS Program subject to their suitability; Evaluation form still needs to be developed using the same IRSS logo.;
Workshop announced for 17-18 March 2004 in Canberra
Chris & Glenys to attend - After discussion with 'Tony' from Canberra who advised that there was no necessity to present a paper.
Chris & Glenys to see if others were experiencing a 'slow start' to program & if there were any ways around this.;
1st April 2004 Pam bought to the attention of the Committee the problems encounter regarding the Referral Process.
Judy explained problem should never happen again, as it had been identified through the hospital system and corrected.
Pam suggested that 3 people be nominated as contact points in the hospital. Gleny's said that she had spoken to Donna Ashby and the problem was rectified.; REHAB Score: With reference to this score, Judy was asked if it was possible to get this Score on Admission and Again on Discharge;

26. 3rd June 2004 Judy Wilson confirmed that the 3 Nominations from TBH for Key Contact personal were accepted. Judy advised that a possible 2 more clients may be suitable. Also Judy Wilson to be transferred to Medical Ward soon, and will advocate the program once she is in Unit; ACAT to assess clients at the level of care on first contact not what is expected after program is completed. Further discussion regarding this problem was had, this may be a continuing problem; Meeting arranged with TRAAC nurses, Allied Health Team, ACAT, Brodribb & RSL to reflect on Discharged Clients
Seek further opportunities to collaborate with other stakeholders to improve the effectiveness and efficiency of health care delivery e.g. continue working with University of Southern Queensland Evidence of links between GPs and other organisations involved in medical research 19 meetings held 2003-2004

1. Tuesday 8th July 2003: Meeting with USQ Centre for Rural and Remote Area Health Re: The SEAM evaluation, finalisation of the survey process. Attendees: Sam Fitzgerald; Michelle Crawford; Prof Desley Hegney; Liz Buikstra; Tony Fallon; Dr Hume Rendle-Short

2. Tuesday 15th July 2003: Meeting between University of Woolongong, University of Southern QLD & GP Connections re: National Evaluation of the Caring Communities Program Attendees: Allan Owen (UoW); Kelly Carruthers (DoHA); Desley Hegney, Liz Buikstra, Tony Fallon, Michelle Crawford, Sam Fitzgerald.

3. Tuesday 22nd July 2003: SEAM Evaluation finalisation meeting with USQ & GP Connections Attendees: Desley Hegney , Liz Buikstra, Tony Fallon, Michelle Crawford, Sam Fitzgerald, Dr Hume Rendle-Short

4. Friday 12th September 2003: Meeting between USQ & GP Connections to discuss possible research project through online development of resources for GPs, OHPs and community Attendees: Sam Fitzgerald, Bruce Vickery

5. Thursday 18th September 2003: Meeting with Palliative Care Queensland to discuss planned funding proposal for Gatton Project Attendees: PCQ, Centre for Palliative Care Research and Education, Mater Hospital, GP Connections

6. Thursday 25th September 2003: Meeting with USQ to develop ICS proposal (Intelligent Care System) this will be submitted to DoHA via Kelly Carruthers for funding consideration in tandem with developed Prevention Program Attendees: Sam Fitzgerald & Bruce Vickery

7. Wednesday 8th October 2003: Meeting with Palliative Care Queensland to develop proposal, key objectives and process plan Attendees: PCQ & GP Connections

8. Wednesday 22nd October 2003 PCQ, GP Connections & Centre for Palliative Care Research & Education to finalise focus group questions Actions: Sam to contact key people in Gatton including Hospital, Domiciliary, Pharmacists & General Practice, schedule focus group meetings for Tuesday 18th November 2003.

9. Wednesday 5th & Thursday 6th November 2003 Oakey Mental Health Project AIMhi with the University of Queensland Attendees: UQ, Mackay Division, SQRGP, Bayside & GP Connections Actions: to plan and implement the AIMhi project in the Oakey region, nominate GP leaders (Dr Kym Palmer & Dr Michael Gordon), develop an educational module based on the materials provided, develop a resource video for use in all the project centres.

10. Tuesday 18th November 2003 PCQ & GP Connections facilitate focus groups in Gatton Attendees: Karen Abbott DoN Dr William Watts Med Super
Carolyn Burke Nurse Annette Connolly Nurse Manager Graham Caton Hospital Pharmacist Gay Skuse OzCare Elaine Horrocks Blue Care Roseanne Morgan RN with Blue Care Dr John Lamb GP Dr John Hudson GP Anne Sharpe PN Trisha Colbran PN Sue Langlands PN Dr Leslie Dhaniram GP Dr Mohammed Sultan GP Val Vaughan Pharmacist Actions: Proceed with development of project proposal with positive reception from focus groups. Suggestion to include all team members in education and to be administrated through GP Connections.

11. Wednesday 3rd December 2003 PCQ, GP Connections, Mater Hospital and CPCRE meet in Brisbane to discuss and finalise findings from Focus Groups.

12. 7th January 2004 GP Connections hosts focus group at the Centre for Rural and Remote Area Health to discuss MedicarePlus Aged Care Initiative and draft response Attendees:
ø Dr Hume Rendle-Short - Chairperson
ø Sam Fitzgerald - GP Connections representative
ø Kerry Thorpe - Practice Nurse
ø Dr Robert Craig - GP
ø Dr Pat Stuart - GP
ø Cynthia Woltmann - Director of Nursing
ø Tricare Charmaine - Nurse
ø Maxine Noone - Lourdes Home
ø Pam Chipperfield - DoN Brodribb Home
ø Carole McGowan - DoN RSL Care
ø Dr Tim Reye - GP
ø Dr Pat Gooch - GP

13. 26th February 2004 Centre for Palliative Care Research and Education Forum into Palliative Care Education in QLD with invitees from north and south QLD including GP Connections.

14. 10th March 2004 Australian College of Rural and Remote Medicine meeting to finalise Dr's Bag for the Dying Online on RRMEO - Rural and Remote Medical Education Online.

15. 19th March 2004 THS Step Down Project Meeting Karen Abbott, Director of Nursing/Facility Manager, Gatton Health Service - Executive Sponsor; Dr Peter Nolan, Director Medical Cluster; Michell McKay, Nursing Director, Medical Cluster; Mary Abbot, Nursing Director, Community and Allied Health; Sue Watson, NUM, Rehabilitation Unit; Gail Cope, Project Officer, TRACC Project; Sue Schmidt, Social Work, Allied Health; Joan Noone, NUM Harbison Unit; Lois Cobon, NUM, Oakey Health Service; Elmo Koelmer, NUM, Oakey Health Service; Denise Breadsell, Project Officer; Sam Fitzgerald, Program coordinator, GP Connections Karen Abbott introduced members of the proposed project team and provided an overview of the draft business plan.
A discussion about related issues occurred and the following were identified:
ø Need for Quality Assessment/development of criteria
ø Appropriate Referral
ø Smooth Transition process
ø Coordinated - single person (nurse)
ø Links to TRACC/ IRIS
ø Communication between key stakeholders
ø Need to work towards integrated Aged Care Services
ø Professional Support (medical/nursing/allied health)
ø Dr Nolan provided a diagram of process required including use of telehealth/2nd monthly seminar-training-social
ø Need for central person only (level 2 RN)
ø Communication link too loose
ø Community Health

An agreement in principal was reached that:
Project:Statement:: Introduction of stepdown rehabilitation services within THSD by June 2004 will provide:
ø Flowchart to describe steps
ø Communication pathway
ø Referral pathway
ø Develop clear criteria for client referral
ø Resources
ø Patient information booklet for rural facilities
ø Therapy resources identified
ø Education for staff/community
ø Utilisation of Allied Health Resource (THSD)
ø Consumer Advocate on Project Team 16.

16. 26 March 2004 Gail Cope left hardcopy information for meeting on the project and process including:
ø Continuity of Care Planning Framework for Queensland
ø TraCC procedure flowchart clinical unit
ø Transition and Continuity of Care Inservice document
ø TraCC Plan Follow up Survey - Patient
ø Fax Message proformas
ø Admission, GP notification
ø Discharge, GP notification
ø TraCC Risk Screening Tool
ø And Explanatory notes

Gail provided a brief description of possible TraCC discharge planning for Rural facility transfers to lead out following step 7 in the flowchart and include Bed Management. Mary and Michelle raised concerns that process needed to be client focused and they did not see a role for Bed Manager in the process and that for the term of the project it could be NUM Rehabilitation and Discharge Planners responsibility to arrange transfer.
Dr Nolan reminded the working party that Sue Watson's position includes 3 hours of management only and she had raised this as an issue on 19.3.04
TH WP suggested any changes to flowchart not be complex (eg like diabetes flowchart)
Dr Nolan raised a number of issues related to him from Dr Hume Rendle-Short
Mary gave a brief overview of Smart State Health 2020 Directions Statement and ISAP Michelle McKay discussed background/funding issues
Sam gave and overview of “More Allied Health Services for Rural Services” (MARS) and IRIS projects
Sam suggested that GP Snippets flyer could be used to communicate project progress and initiatives to GPs and that Behind the Scenes could be provided to the GPs as a communication link between THSD and the Division of GPS

17. 2 April 2004 Michelle tabled the following documents for discussion:-
ø Original Bid $340,700/ Submission to Corporate Office in 2002 for new THSD Step Down/ Slow stream rehabilitation service providing inpatient and outpatient service at Oakey and Gatton Health Service. Final allocation received $177,000 in recurrent funding
ø Emails x 2
ø From Karen Abbott to Michelle McKay re Step Down Rehab - Gatton and Oakey HS date 1/4/04
ø From Andrew McAuliffe to Tracey Silvester re Step Down Rehab - Gatton and Oakey HS date 1/4/04
ø Copy of current (draft) THSD Service Agreement
ø Memorandum from Chris Thorburn, A/DM to Lynn Boundy dated 22/3/04, Subject: Status Report on Step Down Rehab Services to Gatton & Oakey

Michelle discussed in part, THSD Service Agreement on page 7 identifying the strategies and relationship of the following:-
ø Enhance Adult Rehabilitation Services
ø Manage Demand - develop District Bed Management Strategy and related risk management plan/ comply with and effectively utilise Ambulance Redirection Policy
ø Dr Nolan identified that the central focus was the flowthrough of patients into Toowoomba Hospital Rehabilitation Unit in the original bid, and that there was a need to reinforce coordination role to the rehabilitation unit
ø Gail Cope discussed TrACC flowchart and identified need for Bed Manager role in identifying beds available in Gatton and Oakey Health Service to Nurse Managers to reduce number of people contacting Oakey and Gatton Health Service re same.
ø Michelle McKay and Mary Abbott raised need for patient centred approach in developing this service. Patient assessment needed to come first.
ø Joan Noone, currently contacts, Oakey and Gatton Health Service directly.
ø There was general agreement that there was currently no single point of communication between Toowoomba Hospital and Oakey and Gatton Health Service re transfer of patients between facilities.
ø There was general consensus that inpatients could follow TrACC
ø To Step 7, and then the Step Down service flowchart needed to lead off after Step 7.
ø Sam Fitzgerald gave a brief overview of General Practice Advisory Council of Queensland (GPAC) which provides the major mechanism for formal consultation between general practitioners and government in Queensland.
ø Dr Hume Rendall Short currently sits on GPAC.
ø Mary Abbott reminded the members to read the Continuity of Care Planning Framework for Queensland document sent with the last minutes, which is a partnership document signed off in September 2003 by Queensland Health and GPAC providing guidelines for recommended practice for all service providers involved in admission and discharge planning across the hospital community interface.
ø Sam Fitzgerald discussed the More Allied Health Services (MAHS) project, which for the financial year 2002/ 2003 provided 3,378 consumers with access to allied health disciplines in the rural towns surrounding Toowoomba. It is anticipated that the project will conclude at the end of June 2004 and be replaced by the Medicare Plus rebate for allied health services.
ø Mary Abbott gave a brief overview of the powerpoint Directions for Aged Care 2004 - 2011 (draft) and discussed outcomes and identified related policy documents:
ø Smart State: Health 2020 Directions Statement (Queensland Health 2002)
ø Our Shared Future - Queensland's Framework for Ageing 2000 - 2004 (Department of Families 1999)
ø National Strategy for an Ageing Australia: An Older Australia, Challenges and Opportunities For All (Commonwealth of Australia, February 2002)
ø Powerpoint to be forwarded in draft. Mary reminded members re confidentiality and draft issues
ø Dr Nolan identified need for project initiatives to be extended to Mt Lofty for the Toowoomba patients following successful completion of current project, and discussed need for THSD to further develop Aged Care Services and seemless transition of patients from hospital to community.

18. 23 April 2004 Consumer Advocate on Project Team
Mrs Mary Ann Garrahy president of Toowoomba Rehabilitation Unit Support Team (TRUST), welcomed and introduced. Mary Ann gave a brief overview. TRUST has been functioning for last 10 years and has provided $15,000 worth of rehab equipment.
Denise will be spending time with Mary Ann this morning to discuss background and related issues to date.
TRUST has links to Lockyer Valley Stoke Support group and Ipswich Stroke Support group
Flowchart draft 2 for Stepdown Rehab discussed.
Dr Nolan, identified concerns
that bed block from acute unit to Rehab Unit will cause bottleneck for process. Acute Unit issues identified in providing adequate timely assessment for transfer from acute units for SD patients in ward.
Need to raise with patient possibility of SD Rehab program at preadmission clinic
Cross functional medical level referrals need to be timely
Dr Nolan raised possibility of opening 2 extra beds in Rehabilitation unit for period of the trial, with possibility of 4 required if successful
Sue Watson agreed that this could work in reducing bottle necking issues. Need to identify extra nursing hours. Raised concern that short trial period was a risk to implementation of trial as currently no patient in rehab unit suitable for trial scheduled to commence 17.5.04
Sue Schmidt raised concerns about problems with providing adequate AH assessment in acute areas for SD program, especially surgical where there are issues with adequate AH coverage. Need to identify extra staffing hours for trial
Mary Abbot highlighted that this concept was supported by best practice documentation in NDHP and related current literature
General agreement from the project team to support recommendation in first Issues Paper to DE
Dr Nolan/ Mary Abbott/ Sam Fitzgerald, discussed that the Health Passport was developed by a collaborative team in THSD, which included: GP Connection, Auscare, Bluecare, Brodribb NH, RSL Homes, St Andrew's and Dr Peter Nolan at THS developed a Health Passport of patients personal medical information which is given to the patients for other services providers. Pilot during 2004, with 1300 over 75s being issued a Health Passport since January 2004. THS Rehab Unit patients all receive a Health Passport,.
Health Passport's are recognised as part of Aged Care Best Practice
Dr Nolan reported that Oct 2003, Hospital Foundation refused to support the funding to purchase Health Passport packs
Equipment list has been presented by Lynn Boundy and approved by the Assets Committee 22.4.04 for OHS Allied Health Equipment purchase.

Allied Health Working Party formed to discuss Allied Health Service Agreement for RHF, including:-
ø AH hours required development of Day Therapy Program
ø Allied Health Care Plans

19. 7 May 2004 Consumer Advocate on Project Team
Mrs Mary Ann advised that project information has been included in current TRUST newsletter and will be on the agenda at the next TRUST meeting 17.5.04, including a proposal for financial support to be provided towards funding the cost of preparing the Health Passports
Identify current AH funding to Gand OHS to assist in providing funding recommendations in final report
Best practice related issues included inproposal
Equipment list provided from GHS, equipment purchase commenced
AH Working Party report tabled
AH Model of Service Delivery Draft 1 30.4.04. /flowchart
Service analysis tabled
Patient transfers: Rehab, post acute, NHP period Oct 03 - March 04
Hospital Transfer fom/Medical Discharge Summary Chart Audit Oct 03 - March 03
Discussed issues paper presented to the DE by Lynn Boundy 6.5.04 - recommendations not accepted.
No extra beds to be allocated/reallocated to Rehab.
Proposed model needs to identify how post acute patients are managed from the acute wards not Rehab Unit to RHF.
Dr Nolan is currently completing report of Rehab rural referral audit to be presented to Judy March in next few weeks, identifies average response as poor to questions and indicates how current service delivery dictates rural referrals.
Stepdown Rehab patients appear to be working well. No trial required to start next week on 17.5.04 . Focus on acute wards: need to identify how they see the Stepdown process working for post acute patients.
Group discussed need to rethink proposed model to address DE issues. Dr Nolan concerned re bed block issues, reminded the team about recent related complaints.
Continue to seek opportunities to collaborate with other Divisions and QDGP on matters of mutual benefit Evidence of links with QDGP and other Divisions Multiple links with QDGP and other Divisions

Liaised with QDGP in regard to dissemination of IM Module and GP Register
IM Module presented at GPCG annual conference, RACGP biennial computer conference
Division staff maintain involvement in “Division Practice Capacity Building” workgroup
Participate in regular Division Chairs and CEO teleconferences
Participated in Fundholding Discussion
Maintain a close working relationship with the Local Medical Association (LMA) and the Queensland Branch of the RACGP At least one joint activity conducted with RACGP (QLD)

Evidence of issues actioned, by Division GP representatives at LMA meetings		 GP Eye Skills workshop run with RACGP on Nov 1

The GP Eye Skills workshop was run in collaboration with RACGP QLD Faculty on Nov 1, 2003. Approximately 35 GPs attended the workshop, of which 10 were from within GP Connections boundaries.

LMA Weekend occurred on 20th - 21st March 2004

GP Connections to provided evaluation tool and application for CPD events. GP Members on committee were Drs Murray Pietsch and Pat Gooch.
Board members also attended executive meetings representing GP Connections.
Promote and support Division participation on state and federal health related committees eg RACGP, QRMSA Evidence of links with state and national GP organisations 4 links with state and national GP organizations at present

Dr Dilip Dhupelia is a board member and treasurer of QDGP
GP Connections has membership of RRQC and CSQTC. GP Connections also maintains a board position on RRQC.
Dr Hume Rendle-Short sits on GPAC committee
Promote closer links between GPs and HIC to facilitate GP uptake of relevant HIC Business Improvement initiatives such as HIC Online, PKI.
(CDM (Capacity Building & Linkages and Information Management & Support Systems))		 Number of practices provided with information relevant to HIC Business Improvement initiatives

At least one joint activity with HIC on electronic communication		 All practices provided with information

All practices provided with information through Division newsletter insert

One joint activity conducted

HIC Online information session conducted with HIC (Glenn Miles) on July 7, 2003.
Collaborate with DDPHU and other appropriate organisations on matters relating to indigenous health and immunisation
(Immunisation)		 Evidence of joint activities between TDDGP and DDPHU on matters relating to indigenous health and immunisation Membership on DDPHU Immunisation Committee and Immunisation Practice Nurse Education Night
Immunisation Education Night for GPs and practice nurses hosted May 2004

Practice Nurse Adviser, Michelle Crawford is on the committee developing the Food Safety and Pest Control Resource for Indigenous health organized by DDPHU. She attended a committee mtg on 18 Sept 03.
20th November 2003 Immunisation (DDPHU & VIVAS) Workshop 42 Practice Nurses & Staff in attendance
12 May 2004 Team Leaders Dr Robert Rimmer - GP, Toowoomba; Theresa McGorm - Darling Downs Public Health Unit; Claire Hollaway - ACIR; Vicki Bryant - Qld Health Immunisation Program; Dr Neil Parker - Darling Downs Public Health Unit MC plus 32 Practice Nurses and GPs in attendance
Provide opportunities for collaboration with QRMSA on matters relating to Workforce. (WSRGP) Evidence of effective links with QRMSA GP Connections is working with QRMSA to assist rural practices attract locums or additional GPs.

QRMSA will also be involved in assisting the Division develop workforce contingency plans for its rural areas in the later stages of the year.
Continue to provide input into the operations of the Rural Clinical School (WSRGP) Evidence of issues actioned, by Division GP representatives at meetings relevant to the Toowoomba Clinical School GP Connections continued to contribute ideas and suggestions into the operations of the Rural Clinical School

Communications with the Rural Clinical School are ongoing and GP Connections is providing feedback to them regarding research projects. Meanwhile the Clinical School has expressed interest in utilising GP Connections educational resources (eg Aged Care) for their medical students.
Establish a closer working relationship with both the Rural and Regional and Southern and Central Consortiums (WSRGP) Evidence of effective links with Rural and Regional and Southern and Central Consortium's Effective links maintained with both consortia

GP Connections has become a member of CSQTC and member and shareholder of RRQC.
Former CEO of RRQC addressed GP Connections board on consortia issues
CEO of GP Connections met with new CEO of RRQC to discuss collaborative opportunities
Monitor and evaluate the SEAM Program in conjunction with the University of Southern QLD
(SEAM Palliative Care) 		See attached “SEAM” report
Form SEAM Reference Group (members include QLD Cancer Fund, Specialists, Hospitals, QLD Health, Blue Care, Toowoomba Hospice, St Vincent's Community Care and QLD Council of Carers)
(SEAM – Palliative Care Program) 		See attached “SEAM” report


ProgramCONTINUUM OF CARE
GoalTo develop key partnerships and alliances that assist general practice to strengthen the primary care sector
StrategyIncrease consumer input into the development of models of quality care
OutcomesActivitiesIndicatorsResults&Commentary
Consumer perspectives are integral in the shaping and implementation of integrated models of quality care Facilitate a meeting of Division consumers Division consumers to meet, as a group, at least twice a year 2 meetings with consumers held throughout reporting period

In 2003-2004 a new model of consumer involvement has been developed by GPC which will be launched in 2004 -2005. It utilises the consumers in the active role of Community Liaison.
Seek to engage Division consumer involvement in developing new models of integrated care Evidence of consumer participation in Forums on integrated models of care 1 forum on integrated model of care (HMR) to date, 3 consumers participated

HMR Forum 2003 3 consumer representatives on panel and in role play
Continue to engage Division consumers in connecting the Division with community groups At least 3 profiles of community groups in Division Newsletter 4 in the reporting period

July 2003: Literacy Care Australia; Medecins Sans Frontieres; Centrelink Forms Information; Commonwealth Carelink
Seek to engage specific consumer representatives as required in CDM activities. (CDM (Capacity Building & Linkages)) Evidence of consumer input into CDM activities Mental health consumers engaged in the development of Level 2 Mental Health training for GP

Application for training is by GPMHSC and approved. Training commenced in May 2004.


ProgramCONTINUUM OF CARE
GoalTo improve the care of people with chronic illness through the provision of multidisciplinary care services
StrategyRecruit and retain an appropriate allied heath workforce
OutcomesActivitiesIndicatorsResults&Commentary
Improved access to Allied Health Service in targeted communities Continue to monitor the delivery of allied health services (MAHS) (committee comprises representation from rural general practice, Division office, THS, private allied health professionals)
(MAHS)		 Minimum of 2 meetings of the MAHS Management Committee annually Three meetings held within the reporting period

17th September 2003 18th November 2003 31st March 2004
Maintain current allied health services in rural areas (except Clifton – see note below)
(MAHS)		 Contract at least 2 FTEs to provide allied health services by December 2003 2 FTE Allied Health Professionals contracted by December 2003 for 2003-2004
Monitor and review the appropriate use of referral guidelines
(MAHS) 		Evidence of adherence to referral guidelines

Referral guidelines reviewed annually		 Ongoing evidence of adherence to referral guidelines acknowledged through the Central Booking Agency



Referral guidelines reviewed in March 2004

Review the appropriateness of service contracts with service providers
(MAHS) 		Service contracts reviewed annually Service contracts reviewed March 2004
Monitor and review the appropriate use of allied health services
(MAHS)		 Percentage increase in number of allied health services available in rural areas of Division No increase in Allied Health Services due to limited funding
Conduct ongoing consultation with stakeholders and consumers
(MAHS)		 Level of Stakeholder satisfaction Evaluation Survey conducted February/ March 2004

All surveys indicated a consistently high level of satisfaction with the service with results in the high to very high category.
Effectively monitor and review the uptake of the EPC items in rural areas with GPs and MAHS funded allied health professionals
(MAHS)		 Percentage increase in GP usage of EPC items

Increase in number of case conferences / care plans developed in rural areas with GPs and MAHS funded allied health professionals		 Overall, according to HIC figures there has been a 50% decrease in the usage of EPC items though locally through the MAHS program we can only detect a decrease of 16%



There have been a total of 126 care plans developed in this twelve month period representing a decrease of 16% in comparison to last year.

Ensure TDDGP meets all contractual obligations with regards to MAHS
(MAHS)		 All contractual obligations met To date all contractual obligations have been met
Identify and engage allied health workers (psychologists, mental health nurses, social workers, occupational therapists or aboriginal health workers) who are trained in the use of focussed psychological strategies and who will be available for referral from the GP.
(Integrate for Recovery)		 See attached “Integrate for Recovery” report
Ensure that allied health workers who are contracted from the public system (mental health or aboriginal health services) or MAHS program, or any other agency receiving Commonwealth funding to provide additional services are not having a negative impact on existing service delivery. (Integrate for Recovery) See attached “Integrate for Recovery” report
Work with the Toowoomba Hospice and other Health Services to deliver education to the Community and Health Professionals
(SEAM Palliative Care) 		See attached “SEAM” report
Provide a networking link between other health care providers and ensure that each is aware of the services provided to the individual patient and family, thus avoiding duplication
(SEAM Palliative Care) 		See attached “SEAM” report
Provide support to patients through hospital, home visits and telephone service advice under the supervision of a GP (SEAM Palliative Care) See attached “SEAM” report


ProgramCORPORATE GOVERNANCE AND DIVISIONAL DEVELOPMENT
GoalTo improve and maintain an effective, efficient and flexible organisation
StrategyProvide informative communication and professional development for the Board and management
OutcomesActivitiesIndicatorsResults&Commentary
The organisation will have a strong and active Board of Management Conduct a corporate governance program for Board Directors and the CEO CEO performance assessment conducted annually

Board Self-Assessment conducted annually		 CEO performance assessment conducted in June 04



Board Self-Assessment conducted in June 04

Corporate Governance Workshop held in November 03. Topics covered were: Roles of Directors, Fiduciary Duty, CEO / Board relationships
Conduct a Leadership program for Board GPs and other interested GPs as part of Board's succession planning Number of new GPs applying for Board positions 3 new Board Members (Drs Graham Emblen, Murray Pietsch, Pat Stuart).

This years Leadership weekend held on 9 - 10 August 03. 15 GPs attended. Topics included: Capacity Building in General Practice, Quality in General Practice, How to increase Financial viability in General Practice, Models of General Practice - a personal GP perspective. Next Year's Leadership Workshop planned for 7-8 August 04
Conduct a workshop for the Board on Risk Management Risk management workshop conducted by June 2004 Implementation of Risk Management policy planned for early 2005

Risk management policy developed by Commerce Qld in June 04; yet to implemented at Board and Staff level
Appoint a non-medical director to the Board Non medical director appointed to Board by June 2004 Board decided not to appoint a non-medical director

A new corporate governance structure was adopted by the Board at May 2004 Board meeting. As part of this, it was decided to reduce the board size. An appointment of an additional Associate member to the Board doesn't fit with our proposed new structure. The proposal to reduce board size (plus several other changes) will be part of our new Constitution to be presented at the October 2004 AGM for acceptance.


ProgramCORPORATE GOVERNANCE AND DIVISIONAL DEVELOPMENT
GoalTo raise the profile and increase effectiveness of GPs as health planners
StrategyProvide information and resources about National, State and Regional GP policy and strategic direction
OutcomesActivitiesIndicatorsResults&Commentary
General Practice influences policy development in key program areas Canvass the views of GP membership on issues of National, State and Regional relevance such as Medical Indemnity, Medicare Issues Evidence of GP contribution to policy development
100% of GP members have an opportunity to contribute to GP policy 		Invitations were extended to all GPs to contribute their views on relevant GP Issues

Feedback was invited from membership on the following issues:
ø Ways the SCOPE programs could be improved (shared care outreach program for medical patients at the Toowoomba Health Service (THS));
ø Issues around IBNR and the Medical Indemnity Insurance;
ø Declining Bulk Billing rates;
ø Bulk Billing Clinics planned for THS;
ø After hours in Toowoomba;
ø New Allied Health initiative;
ø Future sustainability of general practice;
ø An integrated health system - have your say;
ø In-home rehabilitation support services;
ø Integrate for Recovery - sought support from our members to provide testimonials
Reply to requests for comments on important strategic and policy documents from key stakeholders at national / state / regional levels eg ADGP, QDGP, QRMSA, RACGP Evidence that the Division has capacity to act as a change agent in response to health system reform GP Connections continued to provide comment on important strategic and policy documents

8 Oct 03 Provided feedback to ADGP (Kerry Ungerer) re: Red Tape Report
GP Connections provided a response to the evaluation of the ROMPs program to ADGP.


ProgramCORPORATE GOVERNANCE AND DIVISIONAL DEVELOPMENT
GoalTo raise the profile and increase effectiveness of GPs as health planners
StrategyDetermine opportunities and maintain flexibility to respond to health issues as they arise
OutcomesActivitiesIndicatorsResults&Commentary
Greater Division capacity to respond to emerging health issues Board to conduct regular review of Division programs Progressive achievement of business plan outcomes Progressive Program Reports presented to Board in November 03 and April 04
Board to hold regular “special Meetings of the Board” to discuss and progress important strategic issues Evidence of issues actioned Strategic Board meetings were held in November 2003, March 2004 and May 2004

Issues progressed were around the introduction of a more governance focus for the Board, a more easily understood and succinct format for Program reports to the Board, developed a position statement on Fundholding, developed a policy on appointment of new board members, conducted a scenario planning workshop to determine where we see the Division in 3 years time with regards to its financial position, Review of Board structure (adopted the Tricker Model of Governance), formulated our response to the governments response to the Division's review, reviewed QDGPs board structure
Actively seek non-DoHA related avenues for additional funding i.e. via provision of consultancy services, entering into service contracts with QH for example, conference organisation 20% of funds received from sources other than the Divisions of General Practice program 19.8% of funds received from sources other than the Divisions of General Practice program


ProgramCORPORATE GOVERNANCE AND DIVISIONAL DEVELOPMENT
GoalTo raise the profile and increase effectiveness of GPs as health planners
StrategyDevelop and evaluate Strategic and Business Plans
OutcomesActivitiesIndicatorsResults&Commentary
The Division will achieve annual Business Plan outcomes Provide monthly and annual financial statements to the Board in a meaningful format Programs are managed within budget Financial reports were presented to the Board monthly

All programs came on or in most cases under budget for the year
Conduct a stakeholder survey in preparation for the next triennium funding period i.e. for the period 2004 – 2006 Evidence that evaluation results are used to inform future Division planning Needs assessment survey conducted in February 2004
Develop and submit annual Business Plan, Annual Report, six-monthly report to the Department of Health and Aged Care
Prepare financial statements for audit 		High level of funder satisfaction with Division progress and contractual
Division audited statements provided to Commonwealth, ASIC and other relevant bodies within required timeframe 		The 2002 - 2003 annual report, this year's six month report and the 2004 - 2007 Strategic / Business plans all received favourable comments from the Department
Division audited statements were provided to Commonwealth, ASIC and other relevant bodies within required timeframe

We continue to meet with our DoHA Liaison Officer on a period basis to exchange views and receive feedback. Although we believe we have a good relationship with the State department, having 7 different Liaison officers in 5 years is a challenge for us.
Lodged "Change to Company details" (Form 484) - change to directors and secretary 11 and 18 Sept 03. Copy of financial statements and reports (Form 388) - 14 Oct 03. Submitted Annual Report 2002 - 2003 (bound copy), Financial Statements and P/L for each program to DoHA 22 Sept 03.
Prepare budgets for each program area Budgets approved by the Board before August 2002 meeting Budgets for 2003 - 2004 approved at July 2003 Board meeting


ProgramCORPORATE GOVERNANCE AND DIVISIONAL DEVELOPMENT
GoalTo raise the profile and increase effectiveness of GPs as health planners
StrategyDevelop, implement and continually review management practices and policies for the organisation
OutcomesActivitiesIndicatorsResults&Commentary
The Division will achieve best practice in operation and resource management Implement Policy and Procedures Manual developed by Commerce Queensland (manual commissioned by QDGP late 2002 – 2003 financial year) Manual implemented by June 2004 Implementation of Manual commenced in April 2004; it remains an ongoing process

All staff attended a workshop on 23rd April 2004 to develop a Policy and Procedure Manual specifically for GP Connections; Workshop conducted by Commerce Qld, Toowoomba Branch. Commenced implementation of Manual May 2004
Conduct workplace Occupational Health and Safety Audits Recommendations from audits implemented by October 2003 Recommendations from audits were implemented by October 2003


ProgramCORPORATE GOVERNANCE AND DIVISIONAL DEVELOPMENT
GoalTo raise the profile and increase effectiveness of GPs as health planners
StrategyReview the organisation structure in terms of roles and reporting relationships
OutcomesActivitiesIndicatorsResults&Commentary
The organisation will have a flexible and multi-skilled workforce Hold weekly staff meetings Staff training corresponds to skill needs identified at meetings and in performance reviews Skill needs were identified for each staff member; continuous learning remained a high priority for GP Connections

1 October 2003 - staff training on Division electronic diary. 8 October 03 - staff received training on how to prepare program reports to Board and maintaining a database of tasks performed against Business Plan activities. 2 discussion papers also tabled at this meeting - In pursuit of Quality and Performance; Piloting & Implementing Innovative Funding Arrangements in Qld Divisions
Provide professional development for Division staff based on identified needs 100% of staff undertake training during the year 100% of staff undertook training during the year

Bronwen Barter; Advanced MYOB Course; 2-5 June 2004
Debbie Frost; MYOB Beginners Course; Night Course at TAFE
Joanne Rudge; MYOB Basic Training; 24 June 2004
Fairlie McIlwraith; Creative Writing Course; USQ Summer School - January 2004
Sam Fitzgerald; Research Methods & Online Teaching - Masters; USQ - part of Masters Degree - Semester 1, 2004
Linda Fitzgerald; "Professional Presentations" workshop; AIM - 16-17 June 2004
Nick Pascual; Business Management Course; 22 June 2004 - 3 days
Tim Wilke; Graduate Diploma Australia Institute of Company Directors; 5 day course
Continue to conduct Annual Performance Management Reviews Staff performance to be reviewed by April 2004 CEO continued to meet with staff on an ongoing basis to discuss their performance

Bronwen Barter, commenced as Finance Officer -


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