2017 Submission Abstracts

North Coast Primary Health Network (NCPHN) was thrilled to receive 55 submissions in the 2017 Primary Health Care Excellence Awards. All those who submitted should feel proud of their achievements.

The judges were impressed with the high calibre of submissions and found the task of choosing finalists for each of the four categories a difficult one.

Please see below a list of all submissions, who are listed in alphabetical order within their categories. If you can offer assistance to any of these projects or would like more information on the work they are doing, we encourage you to get in touch.  

Category 1 - Integration and Partnership

Better Together - Integration Strategy

Project aim

To develop a region wide approach to assisting North Coast of NSW Aboriginal and Torres Strait Islander patients to manage their chronic disease and to simplify to multiple systems currently available and to develop relationships with all care providers in the best interest of the patient.

Abstract

Several Aboriginal specific chronic care services existed across different organisations, within the geographical area from Tweed Heads to Grafton. Services existed in the NCPHN, NNSWLHD and Aboriginal Medical Services (AMS’s). These services had various intake criteria/ level of care/ capacity, with poor communication and limited awareness of each other’s services. This created potential inequity of access for the patient, the risk of duplicating care, and an even greater risk of Aboriginal and or Torres Strait Islander patients with one or more chronic diseases falling through the gaps. Ripe for an opportunity for quality improvement, the NCNSWLHD Chronic Disease management team and NCPHN Aboriginal Health team joined together to discuss the opportunities to change the system. Partnering with the local AMS’s, gave this quality improvement initiative the power it needed to develop system wide changes to ensure the best possible treatment and outcomes for Aboriginal and Torres Strait Islander patients.

Contact

Sharyn White, NCPHN

swhite@ncphn.org.au

 

Coffs Coast Collaborative Healthcare

Project Aim

To develop access for the Coffs Coast community to a genuinely collaborative healthcare model that creates lasting changes in lifestyle and wellbeing for our stakeholders, by bringing together the health and fitness industries.

Abstract

The collaborative healthcare model developed between Mid North Coast Physiotherapy and Coffs Coast Health Club has given clients access to a wide range of healthcare and fitness professionals working together to achieve the client's goals. It has removed a large number barriers to accessing appropriate healthcare while saving time, money and frustration, and is genuinely client centred. 

The model focuses on ensuring the client gets the right person providing the right care within their scope, backed by fluent communication channels to follow best practice guidelines. It is a step ahead of what is currently beginning to be trialled with Patient Centred Medical Homes.

Unfortunately, the healthcare industry has historically been heavily geared towards reactive treatment of symptoms, issues, disease and injury. The strength has not been to look at empowering clients with knowledge and support to make lasting lifestyle changes to be proactive about prevention. Likewise, the fitness industry has in many ways been tarnished by slick sales, a focus on body image and vanity to build profits rather than working to be more inclusive and make lasting change for the general population. The focus of both Mid North Coast Physio and Coffs Coast Health Club has been to bring the knowledge, skills and expertise of both industries together to provide all the tools our community needs to make lasting, positive health and wellbeing changes. By addressing the traditional industry shortcomings and combining the strengths of both, we have been able to not only create outstanding health outcomes and client satisfaction, but foster an environment where all staff feel valued, supported and empowered to achieve great things as a team.

Contact

Aaron Hardaker, Mid North Coast Physiotherapy

aaron@mncphysio.com.au

Crystal Methamphetamine Project

Project aim

To provide accessible, evidence-based information to individuals, families and communities affected by crystal methamphetamine (‘ice’) use and to connect communities and services to develop and deliver local actions together.

Abstract

The Crystal Methamphetamine Project (CMP) Community Conversations Model used innovative principles of co-design to work alongside Northern NSW communities and services to develop and implement sustainable strategies to reduce the impact of crystal methamphetamine. Thirteen communities, consisting of 700 Northern NSW community members, participated in Community Conversation events. Communities were also provided opportunities to engage with primary prevention and drug harm reduction strategies through Community Drug Action Teams (CDATs), local SMART Recovery Groups and substance misuse working groups. CDATS now exist in 8 sites and SMART Recovery groups are currently being led in 6 sites across Northern NSW. The CMP has delivered sustainable community and service partnerships across NNSW and is therefore well placed to achieve an excellence award in this category.

Contact

Sam Booker, The Buttery

sam@buttery.org.au

Decision Assist Linkages Project

Project aim

During 2017, the Heritage Lodge Aged Care Facility in Murwillumbah introduced systems to improve end of life education and conversations between residents, families, General Practitioners (GPs) and staff to ensure residents wishes are known and honored, families and staff are supported, and care and palliation outcomes improved for residents.

Heritage Lodge, through Decision Assist Linkages, has committed to developing stronger integration between key care providers in the region, to enhance palliative care delivery for their residents and to develop new pathways and opportunities for networks and communities of practice.

Abstract

The McKenzie Aged Care Group is an Australian, family owned aged care provider with 15 aged care facilities across Queensland, New South Wales and Victoria. One of their facilities, Heritage Lodge Murwillumbah saw the opportunity to pilot the program and develop their Palliative Approach and care delivery through the “Decision Assist, Linkages” project funded by the Commonwealth. The project provided opportunity for the development of network and linkages towards enhanced palliative care delivery for older people in their region. Internally it has focused on developing advance care planning for residents, new practice guidelines including clinical and comfort care measures around palliative and end of life care, upskilling and educating all residents, their representatives and staff on palliative care.

Project aims were developed, specifically to:

  • Reduce unnecessary resident hospitalisations through development of an afterhours GP contact pathway
  • Develop a system for after hour access to emergency PRN medications
  • Develop capacity to support residents through staff upskilling, and revised clinical management guidelines
  • Build a stronger regional network and basis of understanding of role clarification between care providers around resident palliative care and end of life care delivery

This project will include the development of new guidelines and pathways for access to afterhours GP service to avoid unnecessary hospital admissions for the resident. It will also develop a clear pathway for access to after hour’s palliative medicines. Although the project is still continuing, a number of concrete outcomes have already been realized. Since it began in November 2016 we have

  1. Seen an increase in the number of completed Advance Care Planning documents rise from 11.9% to 89% (May, 2017).
  2. The Link Nurses at Heritage Lodge have met with the GP Practice Managers to ensure streamlined contact to GPs out of business hours and for them to be informed of the palliative care changes being implemented.
  3. GPs have been made aware of the Decision Assist website, End of Life pathway form, Life Extinct form, Statement of Choices forms and ‘palliAGED GP app’. The app and Decision Assist website bring together a unique set of Palliative/Advanced Care Planning resources and information accessible to GPs.
  4. The Local Health District, Clinical Nurse Palliative Care Consultant clarified the process for elevation of more complex palliative care needs.
  5. A palliative specialist GP referral form and 1300 hotline advice contact numbers are now available for GP use at Heritage Lodge.

Contact

Helen Bolt, McKenzie Aged Care Group

hbolt@mckenzieacg.com

Dogs Aren’t Our Whole Lives But They Make Our Lives Whole

Project Aim

The aim of this project was to implement a fortnightly Community Support Dog visitation program in the Coffs Harbour Acute Mental Health Unit (CHAMHU) to enhance consumer experience of care by December 2016.

Abstract

The Coffs Harbour Acute Mental Health Health Unit (CHAMHU) can often be a lonely and stressful environment. 

Animal visitation programs provide comfort, entertainment, distraction, solace and a unique form of interaction (NSW Ministry of Health, 2012). These programs have been found to decrease pain, respiratory rate and negative mood, and increase perceived energy level (Coakley & Mahoney, 2009). Many consumers have pets of their own and have minimal contact whilst they are hospitialised. Bright Bessy Dog Training provided a volunteer dog handler and a highly trained community support dog. A risk assessment was completed and NSW Health guidelines were followed. Consumers who have participated in the program provided feedback via anonymous surveys. 89% of consumers reported positive benefits. The program has expanded to six trained dogs due to demand from other wards and Coffs Harbour Mental Health Service has become a sponsoring partner.

Contact

Jackie Cansdell, Coffs Harbour Health Campus

Jaclyn.cansdell@ncahs.health.nsw.gov.au

Integrated Aboriginal Chronic Care Northern NSW Region

Project Aim

To develop a region wide approach to assisting North Coast of NSW Aboriginal and Torres Strait Islander patients to manage their chronic disease and to simplify to multiple systems currently available and to develop relationships with all care providers in the best interest of the patient.

Abstract

Several Aboriginal specific chronic care services existed across different organisations, within the geographical area from Tweed Heads to Grafton. Services existed in the NCPHN, NNSWLHD and Aboriginal Medical Services (AMS’s). These services had various intake criteria/ level of care/ capacity, with poor communication and limited awareness of each other’s services. This created potential inequity of access for the patient, the risk of duplicating care, and an even greater risk of Aboriginal and or Torres Strait Islander patients with one or more chronic diseases falling through the gaps. Ripe for an opportunity for quality improvement, the NCNSWLHD Chronic Disease management team and NCPHN Aboriginal Health team joined together to discuss the opportunities to change the system. Partnering with the local AMS’s, gave this quality improvement initiative the power it needed to develop system wide changes to ensure the best possible treatment and outcomes for Aboriginal and Torres Strait Islander patients.

Contact

Emma Walke, University Centre for Rural Health

Emma.walke@ucrh.edu.au

 

Integration at Antenatal Shared Care Education Events in NNSW

Project Aim

To promote integration of care through interactive education sessions that engage with clinicians, promote patient centred care and increase utilization of Mid and North Coast HealthPathways.

Abstract

The HealthPathways team has been working collaboratively with other PHN programs to assist with improved outcomes from clinically based learning and development activities. The HealthPathways team has guided event owners in the use of relevant HealthPathways as the template for planning the educational content for the event. Antenatal shared care education sessions held throughout NNSW are an example of how this collaboration has helped to achieve excellence for PHN events. It has allowed NCPHN to showcase to a wide range of local stakeholders effective education strategies and the benefits of HealthPathways as an enduring resource for clinicians.

Contact

Kerrie Keyte, NCPHN

kkeyte@ncph.org.au

Lismore Helping Hands

Project Aim

To support Lismore residents and businesses impacted by the major flood on 31 March by connecting them to services and to volunteers and facilitating the distribution of donations in the initial disaster response and recovery phase.

Abstract

Lismore Helping Hands (LHH) was a spontaneous volunteer group that emerged after the major flood in Lismore on 31 March 2017; the most significant flood to hit the city in 43 years. A natural disaster of this scale can have a profound and lasting impact on individual and community well-being. The ability of LHH to rapidly organise and

form partnerships, both informal and formal was critical to improving community health and well-being.

The LHH Facebook group was created on 31 March and quickly grew to 2000

members by 1 April, 4000 by 2 April, 6000 by 3 April, peaking at over 8000 members. The group empowered the community to directly seek and offer help to one another. LHH then opened an on-ground volunteer and community support centre, called The Hub, on 5 April at the empty Lismore Train Station, which was central to the worst-affected area of the natural disaster. The Hub operated for 19 days, until 23 April, with welfare support for some individuals still being provided.

LHH mobilised existing community networks to provide holistic support to impacted residents and businesses and to rapidly organise volunteers. These networks and methods evolved as LHH adapted to the changing needs of the community.

Contact

Elly Bird lismorehelpinghands@gmail.com

 

Our Healthy Clarence

Project Aim

To work together as a community to improve the mental health and wellbeing of the Clarence Valley Community.

Abstract

The high incidence of self-harm in the region of the Clarence was the catalyst for the Local Health District bringing the community together to try and develop solutions to combat this issue. Self-harm was particularly high in the Clarence Valley where young people had taken their lives over

The Local Health District and Primary Health Network have been working as partners to establish a steering committee and projects to minimise suicide and self-harm in the region.

The steering committee was able to identify the need to the Commonwealth and the state governments who provided funding for targets projects and funding to trial new approaches to suicide prevention in the region.

Trial activity will focus on a follow up service in Northern NSW for people who have attempted suicide and have presented at the emergency department utilising Beyondblue’s The Way Back Support Service.

Informed by localised needs assessments, The North Coast Primary Health Network (NCPHN) established 5 focus LGAs for its suicide prevention activities: Clarence Valley, Tweed & Byron, Lismore, and Kempsey. These 5 LGAs have the highest rates of suicide as well high rates of disadvantage of access for areas outside of main centres. A Needs Assessment was used as the platform to commence activities relating to community engagement and consultation.

During the 2017-2018 year the trial emphasis is on the following activities

  • Procurement and Tendering for a consortium to deliver the follow up service
  • Clinical Advisory group developed to support governance and implementation of the service
  • Steering Committees maintained to provide oversight to the delivery of the service across targeted LGAs

The Steering Committee has been established and has been instrumental in development of a single action plan which has seen an increase in funding of vital services across the region, the establishment of a ‘Headspace’ in Grafton and significant community led events and activities.

Contact

Olivia Pantelidis, NCPHN

opantelidis@ncphn.org.au

 

Preoperative Shared Care

Project Aim

To improve Port Macquarie patient readiness for major elective surgery through preoperative Education and further GP involvement from June 2017 to December 2018.

Abstract

The current waiting time for major elective surgery in PMBH is approximately 12 months. Evidence shows that optimising patient’s weight, diabetic control, treatment of iron deficiency, smoking cessation and muscle tone contributes to improved peri operative outcomes. The Preadmission Clinic identified that this was not happening adequately in the primary care setting, and patients generally were ill informed on how they could help improve their own outcomes. Preoperative Shared Care aims to use the current waiting time to better prepare patients for surgery by following an evidenced based preoperative shared care HealthPathway with their General Practitioners. The take home message was of preoperative care needing to commence as soon as the surgeon and patient agree to proceed with surgery.

Contact

Brenda Rattray, North Coast Primary Health Network

brattray@ncphn.org.au

Safe Transition of Care

Project Aim

The Aim of the Mid North Coast Safe Transition of Care Program is to improve patient safety through improved clinical handover when a person or patient transitions between care providers and/or care environments.

Phase 1 of the Program specifically focusses on discharge information provided by MNCLHD facilities to General Practice and Residential Aged Care Facilities.

Abstract

Mid North Coast General Practitioners have expressed concerns that when people are transitioned from hospital to community/primary care, information required for safe clinical handover between hospital and primary care practitioners often comes too late or not at all. Case studies have been discussed where a person’s health has been significantly impacted to the point of re-admission to hospital or deterioration and death which may have been prevented if General Practice had the information required to provide safe care after hospital discharge.

The project has brought General Practitioners, Mid North Coast Local health district (MNCLHD) specialists, IT, Admin and Nursing staff together to work collaboratively to support improved clinical handover during the transition of care, and has already achieved its first ‘quick win’.

The project commenced on 13 March 2017. In the short timeframe that the project has been in existence, through collaboration, the project has identified:

  1. Simple mechanisms to ensure GP data is up to date in MNCLHD systems so that discharge summaries get to the right practice and GP
  2. That no discharge summary information is being received by GPs for maternity, mental health or outpatient clinics (such as fracture clinic)

The NCPHN Quality Improvement Team will continue working with GPs across the MNC to ensure systems for providing up to date GP contact details to MNCLHD on a regular basis. The currency of GP detail will expedite timely transfer of patient information.

Contact

Isabel Butron, North Coast Primary Health Network

ibutron@ncphn.org.au

Category 2 - Innovation

Art on Bundjalung Country

Project aim

Between 2016 and 2018, empower Aboriginal communities in the Bundjalung Nation to be healthy and resilient through the application of art and community conversations.

(Note:  art is inclusive of dance, basket weaving, printmaking, sculpture, carving, and tie dying.)

Abstract

Following conduct of two successful art exhibitions (where art was sourced from local Aboriginal communities) a group of enthusiastic health practitioners and art professionals met in 2016 to progress a further exhibition. The intent was provision of opportunities for local artists to have their art seen and sold in the Lismore Gallery. This initial idea grew and ultimately became the subject of a submission to the North Coast Primary Health Network (NCPHN) for funding of both an exhibition, and conduct of five workshops.  The workshops would be facilitated by local Aboriginal artists and cover a variety of art forms and techniques. They would promote existing artists and support/develop those who had never previously exhibited.  The submission was successful with The Art on Bundjalung Country Project becoming a reality.  The project has three major goals, - first to provide Aboriginal communities in the Bundjalung Nation connections with the arts as a pathway for conversations, capacity building activities and healing. Second, to build community resilience by developing links to economic sustainability through art. Third and last, to work collaboratively the Lismore Regional Art gallery, Arts Northern Rivers, the University Centre for Rural Health, Aboriginal elders, Aboriginal Medical Services and Land Councils to enable a coordinated, holistic, inclusive and culturally appropriate approach. The NCPHN has employed a Senior Project Officer, “Art on Bundjalung Country” to progress the project.

Contact

Sarah Bolt, NCPHN

sbolt@ncphn.org.au

Development of Nurse Led Clinics at Southern Cross University

Project aim

To develop a number of nurse led clinics within the Southern Cross University Medical Practice to enhance patient experience/outcomes, create more learning opportunities for health students and generate an increase in service income.

Abstract

The Southern Cross University Medical Clinic is a unique and rapidly growing practice housed within a large multidisciplinary student led health clinic.  Opening its doors and offering a fully Bulk Billed GP service to the general public in May 2015 has posed a number of significant challenges in providing an effective service.  As a team of nurses, GP’s and reception staff, the project has been able to effectively and swiftly increase health student learning opportunities, increase practice income and develop, implement and review a system of care for patients by incorporating the philosophy of the Person Centred Medical Home which promotes client health and wellbeing through education, comprehensive care, and encouragement of client self-management. 

Contact

Jenni Heuchmer, Southern Cross University Health Clinic

Jenni.heuchmer@scu.edu.au

Eclipse

Project aim

The Aim of Eclipse is to build connection, support and resilience for those in our community who have survived a suicide attempt.  

Abstract

After a member of the public approached Lifeline Mid Coast (LLMC) requesting help to stay alive, a committee formed to research and develop a program to support people who are struggling after a suicide attempt.  Eclipse is the result of this first contact and to date the result has been extraordinary with Eclipse participants reporting significant reductions in thoughts of suicide and no re-admittance to ER or hospital.

Eclipse took 4 years of planning and was launched in late 2016.  It began with collaboration between LLMC and the Californian Didi Hirsh Suicide Prevention Centre.  The project was strengthened with the inclusions of Lifeline Research Foundation and the University of New England as partners in this project.

Contact

Lea Harvey, Port Macquarie Hastings Suicide Prevention Network

lea.leahy@bigpond.com

Elderly Health Literacy in Faringdon Village

Project aim

During 2016 improve the health and wellbeing of people living at ‘Faringdon over 55 Village’ through conduct of a pilot Health Literacy program.

Abstract

Ageing is common and complex. Aged people who have timely access to appropriate healthcare services, and receive co-ordinated and integrated care from a multidisciplinary team across the continuum of primary, secondary and tertiary services will have:

  1. Reduced Length of Stay (LOS), decreasing the risk of hospital acquired complications. 2. Slowed ageing progression, and require less acute hospital admissions. 3. Reduced Emergency Department (ED) utilisation. 4. Improved quality of life through social engagement and community participation
  2. Improved health literacy and self-management skills.

In the current healthcare climate, there is increasingly recognition of the need to develop strategies that keep patients well in primary care, to free up specialist resources for acute events and complex cases and for patients to take increased responsibility for their care.  

This project piloted introduction of a Health Literacy Program within an over 55’s senior’s community, - Faringdon Village, (located in the Nambucca Valley). During December 2016 residents were invited to identify and prioritise ten issues important to their wellbeing. These prioritised areas became the subject of the pilot. Members of local community service organisations joined the resident team and worked with them to develop a program to address their prioritised areas.  The program was varied, flexible, involving delivery of presentations, and interactive discussions. Importantly, the program was delivered in the modality they believed best met their own need. Residents also drove the sustainability ideas’ process’ co-opting external organisations to work with them, e.g. Men’s Shed and NSW Police. 

The pilot has illustrated many positive outcomes, but one in particular relates to residents awakening and awareness of the My Aged Care (MAC) portal. They have described their new found ability to navigate the portal to receive services for the person they care for, and for their own use as it relates to self-management.  The pilot demonstrated co-design of health care is attainable. Consumer engagement and guided self-direction is an efficient manner of improving health services.

Contact

Luisa Eckhardt, Nambucca Valley Integrated Care Initiative

luisa.eckhardt@ncahs.health.nsw.gov.au

Embedding Digital Health into General Practice Workflows

Project aim

To innovatively embrace the Commonwealth move towards a National digital health system in the Ochre Health Grafton practice by enabling our practice be fully digitally ready, upskilling nursing staff as practice champions for eHealth and embedding SHS upload practice into our CDM work via in-practice nurse incentive scheme.

Abstract

Amongst the Ochre health practices, Ochre Health Grafton is leading the way for digital health uptake and has implemented an innovative but practical scheme to embed eHealth into workflows as efficiently as possible and with a patient-centred mindset. 

Between June 2016 and June 2017, staff of Ochre Health Grafton worked persistently to become digitally ready as a practice and to embed Shared Health Summary uploads into their daily workflows so that consultations were not compromised, patients were fully engaged in the process and the practice met its compliance targets for PIP eligibility. The practice is regularly uploading SHS on a daily basis and exceeded its PIP requirements 

Research suggested that the practice’s patients accessing Chronic Disease Management services who are supported by the practice’s nursing team as well as their GPs would benefit from SHS uploads to ensure better care coordination. This guided an area of focus in the first instance of embedding ehealth functionality into the workflow.

The identification of the practice nursing team as the champions for eHealth has been driven and supported by the Practice Manager, Carol Pachos, who could see that the place for Shared Health Summaries sat with nurse clinicians who were already assisting the GPs with patient assessment, identification of patient needs and making arrangements for services related to GP Management Plans and Team Care Arrangements within their Chronic Disease Management roles. 

The success of the initiative was supported by the attention to upskilling and education around ehealth policy and procedure as well as how it will benefit each of the stakeholders to achieve smooth change management despite a variable roster of GPs due to international, sabbatical and short term contract situations across the 12months. The practice is being championed within Ochre Health as a leader in eHealth implementation and their senior practice nurse Mary-Anne Cole is currently writing a handbook on CDM for practice nurses that will assist other practices to use their model. 

Contact

Carol Pachos, Ochre Health Grafton

gmc@ochrehealth.com.au

General Practice Quality Improvement Support Team

Project aim

To build change management capacity within General Practice by facilitating quality improvement via an innovative NCPHN support model. 

The General Practice Quality Improvement Support model must:  1. support use of change principle methodology in planning continuous quality improvement

  1. encourage use of meaningful clinical information system data to inform change priorities
  2. offer regular face to face support to achieve practice-identified goals and

4. document improvement initiatives in a widely acceptable format that highlights increasing capacity for change.

Abstract

Changes to many facets of General Practice business structure and workflow are already happening or indicated with the upcoming PIP restructure, the anticipated release of the 5th edition RACGP standards for accreditation, the recent adoption of opt-out policy for digital health and the lead site trialling of PCMH business modelling. 

In the North Coast footprint, as at Feb 2015, 87% of General Practices were accredited against the RACGP 4th edition standards of practice, 5% had a Continuous Quality Improvement plan in place, 24% used a clinical information system with a data analysis tool and 3% regularly documented QI initiatives to evidence capacity to implement change (mostly associated with historical work as part of the APCC).

In 2015, NCPHN uniquely committed to investing in General Practice with the implementation of a nine-person General Practice Quality Improvement Support Officer team to support the 181 practices across the footprint. This program included offering monthly face to face visits, support to implement QI initiatives within practices as well as deliver news, event information and access to training opportunities to support practice operations and professional development. The team measured success across an extensive range of KPIs but especially QI planning, Accreditation gain or maintenance, digital health readiness/ utilisation and data extraction/PDSA completion as indirect measures of capacity to implement and document change. 

During the 2016-2017 financial year, 87% of all existing 176 practices maintained their accreditation and an additional 5 practices were supported during the accreditation process across 2017. A further 4 practices are registered to undertake new accreditation within the next 12 months, and another two are currently interested in NCPHN preliminary support to register, with the new goal of 90% of all practices in the footprint being accredited attainable by Jun2018. The team also increased participation in the MI program from 24% to 61.5% during this period (installing Canning data extraction tools in over 96 practices, implementing change education initiatives via the NCPHN MI Program and various projects and collaboratives and documenting action undertaken via the Improvement Foundation’s QI Connect portal). Over half of these practices now consistently upload data to QI Connect with an average of 60 PDSAs per quarter being uploaded.100% of all practices in the footprint were offered QI support from the team via face to face visits and most practices engaged with the team in QI planning at some level with high numbers creating QI plans for 2017 calendar year. Digital health readiness and embedding of SHS upload into workflows also showed a marked improvement during 2017 given the face to face support provided by this team and the commencement of the eHealth PIP from May 2016.  

Key to the success of the project was the General Practice QI Support Officer’s knowledge of their practices across the range of geographies and demographics in the footprint and developing relationships with these private practices and AMS corporations. Additionally, a fully committed and dedicated approach to change management methodologies and their application in a General Practice setting, by this team, has enabled documentation of the ongoing achievement by practices to make small and sustainable improvements. Support Officers also focus on building the practice teams’ capabilities and skillsets so that innovative solutions can be found that will lead to timely and able responses in the changing Primary Care sector environment into the future.

Contact

Linda Ward, NCPHN

lward@ncphn.org.au

 

Healing for Dhalayis (boys, girls, children)

Project aim

To increase the holistic health outcomes for Aboriginal children and young people effected by trauma and childhood abuse.

Abstract

Turning trauma into hope, ‘Healing for Dhalayis’ is a community project which aims to provide comfort, reassurance, and cultural connection for Aboriginal and Torres Strait Islander children and young people experiencing severe childhood abuse and trauma.  

The project incorporates the design of Aboriginal specific art, stories and symbols that are being made into trauma quilts and pillows. The trauma quilts and pillows are used by health professionals in the crisis phase of the NSW Health response to abuse victims. These unique, handcrafted designs are created by Aboriginal men, women and children in the Kempsey area, and are offered specifically to Aboriginal children and young people, entering into the Joint Investigation Response Team (JIRT) Program as a result of an allegation of serious childhood abuse. These items represent caring and sharing within the Aboriginal Community, are a symbol of unity, assist with the management of trauma related symptoms and enhance the client’s spiritual/cultural therapeutic treatment and experience. 

Contact

Sharon Noble, Kempsey District Hospital

Sharon.noble2@ncahs.health.nsw.gov.au

Healthy Choices Through Social Action Youth Theatre

Project aim

To empower young people, aged 12- 25 years to make positive decisions concerning their health and well-being by engaging them in youth devised performances and workshops.

Abstract

The health and wellbeing of our young people determines the future of our societies.

“Young people are the foundation for effective development, and if engaged they will improve many of the structural development challenges that we face today, including enhancing the cohesiveness of families and communities, reducing health risks and advancing livelihood opportunities” (1)

Byron Youth Theatre’s (BYT) core belief is that young people have the capacity to develop and share new ideas and approaches to issues they experience.

Solutions can be reached through a collaborative framework facilitated in partnership with adults. BYT productions and workshops empower young people to determine decision making and problem solving skills while fostering awareness of their own resilience.

Contact

Lisa Apostolidis, Byron Youth Theatre

Byronyouththeatre2481@gmail.com

If These Halls Could Talk in Bonalbo

Project aim

To engage community participation by the Bonalbo & district community in Arts Northern Rivers "If these Halls Could Talk"a collaboration with ABC OPEN & Southern Cross University project where their artist Grayson Cooke could make a film relating to Bonalbo & District Memorial Hall and ABC Open would document stories about the hall.

Abstract

Over 200 of the 508 residents in Bonalbo took part in the filming of Grayson Cooke's "Bonnywood Rising". The hall committee worked tirelessly in a voluntary capacity to facilitate hall access and engage all aspects of the Bonalbo community: the elderly, teenagers, children, indigenous, multicultural, disabled, unemployed, workers, mothers were all there having fun and giving their best to enable this project to be fulfilled. Community members were actively encouraged to bring their halls stories to the artist, a reserved people this took some outreach and encouraging with outstanding success.  Over 250 people attended the screening showing that the community had come together and general moral was up!

Contact

Marion Conrow, Bonalbo & District Memorial Hall

marionconrow@yahoo.co.uk

Innovation for Carers

Project aim

To provide a unique experience in a warm and inviting environment that is a fully operational retreat where the carers can have respite prior to returning to their caring role.    

Abstract

 Joyland Carers Retreat is a relatively new business with just over two years of operation since January   2015. Its objectives are to raise awareness of carers within our communities and recognise the gift of giving these carers contribute to others lives and    the significant savings to tax payers these carers provide with little recognition. Innovation for Carers aim is to deliver an innovative and sustainable caring facility for unpaid carers in the community.

Contact

Ellen Slater, Joyland Carers Retreat Association Inc

joylandcarersretreat@gmail.com

Improving Domestic Violence Identification and Response at LBH ED

Project aim

To improve domestic violence (DV) identification and response by implementing and evaluating routine domestic violence screening in Lismore Base Hospital Emergency Department (ED).

Abstract

One in four Australian women have experienced physical or sexual violence from an intimate partner since the age of 15 (1). Women experiencing violence are likely to attend the emergency department (ED) more frequently than other women (2) and there is significant evidence that screening increases DV identification and has important safety and education benefits (3). However, there are many barriers to DV screening in EDs and a previous trial in NSW achieved only a 10% screening rate.   This project adopted a series of innovations to overcome barriers and implement routine DV screening and response in the ED. A brief, validated tool not previously used by NSW Health was identified to address time constraints in the ED; an interdisciplinary partnership between ED and Social Work was developed to facilitate a seamless referral pathway for women who disclose DV; and local project champions were trained and mentored to support the project’s implementation. Importantly, clinicians and policy makers from all levels of the health service were engaged to build support for the project. After initial feedback suggesting that the barriers were too great, the project was ultimately sponsored by the Ministry of Health and expanded to a three-site trial with statewide policy and practice implications.   Routine domestic violence screening for women aged 16-45 and one-hour social work response was implemented at Lismore Base Hospital ED in May 2017. In the first month, 30% of eligible women were screened, a 300% increase from the previous trial. Four clients met with social workers and received assessment, support and referral. The project will continue for six months and a comprehensive evaluation will be conducted to inform potential statewide rollout of the program.

Contact

Ellie Saberi, Women’s and Child Health Team, NNSWLHD

Ellie.Saberi@ncahs.health.nsw.gov.au

 

Heroes without Capes

Project aim

Recognition of the Byron Bay Community Associations (Center) role, in meeting the health and wellbeing needs of the disadvantaged, elderly and general population.

Abstract

The Byron Bay Community Association is a not for profit organisation operating from a purpose-built community Centre in the center of Byron Bay. With very little local, state or Federal Government support, it runs a number of programs specifically tailored to the community’s needs. the Centre acts as a hub for community engagement and connectedness. From a health perspective, the roles of advocacy and connectedness contribute significantly to improved social determinants of health and ultimately better well-being.

Contact

Cat Seddon, Byron Community Centre

communityservices@byroncentre.com.au

Medication Safety by Reducing Owed Scripts

Project aim

To improve patient safety in medication management by reducing owed prescriptions in the Hastings Macleay region.

Abstract

GPs, pharmacists and residential aged care facilities in the Hastings Macleay region had been frustrated for many years by owed scripts. Owed scripts is medication supplied to a patient without authorisation or a script from a GP. Owed scripts are sometimes dispensed by pharmacists when patients with high medication dependence urgently need medication but cannot access their GP for script renewals or were unaware scripts are due for renewal. Owed scripts present significant patient safety, administrative and legal risks. The North Coast Primary Health Network (NCPHN) successfully reduced owed scripts by 53 per cent in the Hastings Macleay region through an innovative quality improvement project implemented in 2016. The Medication Safety by Reducing Owed Scripts project was one of the first projects of its kind in Australia and has improved health outcomes, reduced workload and improved communication amongst primary care clinicians in the Hastings Macleay region. The key factors attributable to the success of the project included: the focus on building the health literacy and self-management capacity of patients; clinicians driving the solution design and implementation of the change; and facilitating communication and relationship building between providers. 

Contact

Monika Wheeler, NCPHN

mwheeler@ncphn.org.au

 

Mid North Coast Joint Needs Assessment Project

Project aim

To understand which health and service issues on the Mid North Coast are most needing of a joint Local Health District and Primary Health Network response.

Abstract

The Mid North Coast Joint Needs Assessment Project collected the extensive information recorded through the Mid North Coast Local Health District and North Coast Primary Health Network Needs Assessments, merged that data into one list of issues and then applied a prioritisation tool to determine what issues should responded to. The collaborative approach to conducting the Needs Assessment and the advancement in thinking and technical tools for understanding and ranking health issues is innovating health planning and improving the focus on where effort most needs to be placed to improve the health of the Mid North Coast population.

Contact

Tracy Baker, NNSWLHD

Tracy.Baker@ncahs.health.nsw.gov.au

Mid North Coast Regional Social Plan 2017

Project Aim

To provide an evidence-based social plan to serve the people of the Mid North Coast though information targeted to agents of community change.

Abstract

The Mid Coast Communities Regional Social Plan outlines the Mid North Coast’s current strengths and needs, and identifies goals that encourage happier, stronger communities. The introduction details the mixed methodology and scope of the report to follow, and details our region’s geographic and demographic characteristics. The body of the report details key concerns affecting life for community members in the Mid North Coast region. The concerns have been selected with Mid Coast Communities’ social vision in mind: ‘People we work with thrive, and our local communities are places where everyone belong’. This report considers each concern (i) as a general factor affecting life in Australia; (ii) in reference to Mid North Coast communities’ particular strengths and aspirations, and; (iii) in terms of potential solutions or recommendations for change over the next five years. Finally, the conclusion summarises ways to address the issues described in the body of the report, in line with the goals set out in the introduction.

Contact

Justin Gaetano, Mid Coast Communities

justingaetano@midcc.org.au

NCPHN Procurement Manual - Cementing a Segment of the Commissioning Cycle

Project aim

To have in place a Procurement Manual focusing on person centred health outcomes through the detailing of processes to be followed to ensure value for money, good governance and probity in procurement of commissioned services.

Abstract

Decades of fragmentation between and within health and social care organisations has left a legacy that often creates barriers to achieving significant change in the way providers work together.  This has ultimately limited the achievement of health outcomes for the Australian population. 

Primary Health Networks were established to act as commissioners to assist with “joining up” the primary health care system.  As commissioning for outcomes is new to the Australian health care environment, a new range of competencies and capabilities must be built within the sector, and within the PHNs.  As such, the NCPHN decided to develop a Procurement Manual to provide a practical guide to procurement for health commissioners, to build competency in this new arena. 

Traditionally a procurement process would have been associated with a detailed number of steps to attain services and would not explicitly be developed with improved person centred health as a primary goal.  The North Coast Primary Health Network set out to change the philosophy associated with the procurement process, to one aligned with the Commonwealth Government’s focus on person centred care and delivery of health outcomes as measurements of success.

As we strengthen our collective skills and experience in commissioning, the Australian population will reap the benefits of a greater joined up health system.

Contact

Shay Ataii, NCPHN

sataii@ncphn.org.au

The Immunisation Project

Project aim

The Immunisation Project aims to be responsive and creative in its approach by developing and trialling new and innovative strategies to tackle immunisation on the North Coast.

Abstract

The Immunisation Project has been developed out of the Immunisation North Coast Action group (INC). The INC plan contains four high level key lines of action: 1) Support Immunisation providers to implement Report, Recall and Remind

2) Ensure the region is well supplied with health professionals skilled in providing effective immunisations

3) Increase visibility through engagement and communication

4) Develop collaborative leadership arrangements

The Immunisation Project is a lead in many of the strategies to strengthen the INC key lines of action. The Immunisation Project itself is a whole of health system response, but has a focus on the primary care role of immunisation. 

Many people on the North Coast have a unique concept of immunisation, and the barriers our primary health workforce face here are not the same in other parts of Australia, or the world.

Evidence suggests that there is a high presence of immunisation hesitancy and vaccine refusal on the North Coast of NSW. In a recently published article (Beard et al 2016) suggested there is a cluster of parents who have a registered objection to immunisation on the North Coast, hovering between 6-12%, which is around 10% higher than the national average. 

In correlation to this statement, the immunisation rates on the North Coast have been historically low for a number years. 

The Immunisation Project aims to be responsive and innovative in its approach by creating and trialing new and innovative strategies to tackle immunisation on the North Coast.

Contact

 Sharyn White, NCPHN

swhite@ncphn.org.au

The Patient Centred Medical Home Journey

Project aim

To support general practices and Aboriginal Medical Services to provide more patient centred, accessible, coordinated and comprehensive care through the application of the transformational model of the Patient Centred Medical Home (PCMH).

Abstract

Following implementation of the PCMH model in the USA, the North Coast Primary Health Network (NCPHN) recognised its strength and application to Australia’s climate of increasing demand for care.  For example - in Australia, one in two people have a chronic health condition and one in five people have at least two chronic health conditions. There is a potentially preventable hospitalization for chronic conditions every two minutes (Australian Government Department of Health, 2016). 

It is well recognised that a robust primary health care system has the potential to reduce hospital admissions, improve health outcomes and enhance the patient experience. The Patient Centered Medical Home (PCMH) model aims to achieve this robustness through transition to a new way of delivering care which is patient-centered, comprehensive, coordinated, accessible, and focused on quality and safety. 

The project introduces the PCMH framework and model to General Practices and AMSs within the NCPHN footprint. The PCMH model is centred on the patient and their needs, with health and community services coming together to provide a connected and integrated approach to care. Key concepts of this model include a holistic approach rather than being disease or organ specific; care that is delivered closer to the patient’s home; care based on long-term relationships; an emphasis on self-management where the patient is an active participant; care which is preventative and proactive; and care which is less costly to provide (North Coast Primary Health Network, n.d.).

The project has four (4) deliverables, three of which have been implemented; - the fourth pulls together the previous three through trial and adaptation. Initially the team needed to develop resources which involved general research of the topic, and liaison/consultation with Australian /international PCHM experts, and other key stakeholders. Development of evidence-based PCMH resources has occurred. Significantly, indications highlight wideranging engagement with the concept, tools and materials.  Outputs listed in this document illustrate current success of the project.

Contact

Safa Rahbar, NCPHN

srahbar@ncphn.org.au

Virtual Senior Centre

Project aim

Feros Care has established Australia’s first “Virtual Senior Centre” - an innovative online live video platform that supports technology assisted group, social, special interest and wellness activities for seniors.  

Abstract

The Virtual Senior Centre allows members to participate in live events over an online portal from multiple sites simultaneously.  It provides a schedule of interactive virtual activities accessible by seniors regardless of whether they live in a retirement village, residential aged care facility, in their own homes, or even in a mobile home. The virtual activities that have been run by Feros Care through the Virtual Senior Centre to date include: Virtual learning; Virtual consultation; Group exercises; Virtual games; Virtual tours; Relaxation activities; Cultural and religious events; Artistic events; Political discussion; Craft and Cooking event; Social chat clubs.

Contact

Jennene Buckley, Feros Care

JenneneBuckley@feroscare.com.au

Women’s Cancer Screening Collaborative

Project aim

To improve breast and cervical screening rates through the delivery of structured, clinician led general practice quality improvement and health literacy interventions.

Abstract

Effective population cancer screening programs reduce cancer related death and illness.  In the North Coast region 4 out of 10 women are overdue for breast and cervical cancer screening.  There are significant health equity issues inherent in cancer screening, with Indigenous, Culturally and Linguistically Diverse, rural and LGBQT women less likely to screen.  The Women’s Cancer Screening Collaborative (WCSC) is improving women’s cancer screening participation through primary care led quality improvement.  The WCSC is the first Collaborative in Australia to target women’s breast and cervical cancer screening.  The WCSC draws on the expertise of NCPHNs Community Engagement, Health Literacy, Patient Centred Medical Home, Communications and Practice Support teams and works closely with North and Mid-Coast Local Health Districts, BreastScreen NSW and the Cancer Institute NSW. This partnership approach allows the program to wrap a fantastic range of technical support around participating practices to assist them lead change. Population screening is a Department of Health ‘headline indicator’ for Primary Health Networks. 

The WCSC began in September 2016 and continues until June 2018.  The WCSC is jointly funded by Cancer Institute NSW and NCPHN.

Contact

Sara Gloede, NCPHN

sgloede@ncphn.org.au

Wound Warriors

Project aim

Raise the profile of Wound Management and move away from ‘historical practice’ and initiate an improved patient journey for the Chronic/complex wound patient, between primary health care and the acute sector.

Abstract

Chronic wounds represent a silent epidemic affecting a substantial portion of the world population. (Graves & Zheng. 2014)

Given the impact of chronic wound management on health care expenditure, and its exclusion from consideration in the ‘chronic disease’ forum, wound prevention should be a priority in public health initiatives.  Most of the costs incurred are in the hospital system as compared to primary care services.  As the aged population grows, costs are likely to rise, this problem and the impact on our health system will continue to grow unless we address our current practice.  There is urgent need to improve and build a ‘streamlined’ and integrative management of these complex patients,  facilitating an improved journey between the primary and acute care setting, involving all disciplines and the patient.

A need was identified to move away from the historical practice of ‘dressings and antibiotics’, discharge and readmit.  This historical practice guided nursing and medical approaches to wounds, rather than integrative, updated and evidence based focus on management.  The historical approach results in significant financial and social burden to both the inpatient acute system, primary care and ultimately a significantly reduced quality of life for patients living with unhealed complex wounds.  

  • The ‘Wound Warriors’ project aims to raise the profile of Wound Management in the Health Sector.
  • Motivate, improve knowledge and confidence amongst nursing and medical staff (in Acute and Primary Setting) in the management of wounds. Improving skills in the diagnostics and management of chronic/complex wounds, skin and soft tissue infections.
  • Change from historical practice to an integrated care model incorporating evidence based and investigative care model.
  • Improve communication and de-isolate the patient and individual specialties, working together to a common goal.

From a GP perspective:

“Reduce the significantly ‘revolving’ door of admission – discharge- readmission.  bringing Primary Health, Specialist Care, Community Nursing and the Hospital System all together as Wound Warriors learning together about wound care, using the same language and approach towards wound care improves patient care and improved out comes.   We are spending a lot of money on Sepsis management and using very expensive Antibiotics. The Wound Warriors starting at the Prevention end of Sepsis and a multidisciplinary approach there will reduce the incidence of Sepsis and save millions of health care dollars. By treating wounds early appropriately and with continuity of care there will be less resistance development to antibiotics and prevention of secondary complications especially in Diabetes.  -We do know how well a multidisciplinary team works for cancer treatment. This innovative approach of the wound warriors will revolutionize wound care and improve the outcomes out of site. It also helps to remove barriers amongst the different professional groups.”  Dr D Eburn

Contact

Anne Fowler, Coffs Clinical Network

Anne.fowler@ncahs.health.nsw.gov.au

Category 3 - Improving Health Care Access and/or Reducing Health Inequity

Bridging cultures – partnering with patients in their health care journey

The aim of this project is to bring the readmission rates of Aboriginal patients into alignment with their non-Indigenous counterparts.

Abstract

The clinical practice improvement project was established to address issues related to the high re-admission rates seen within the Aboriginal population.  61.5% of Aboriginal patients admitted to Port Macquarie Base Hospital with a diagnosis of Acute Coronary Syndrome, were re-admitted to hospital within 28 days of discharge.  Using clinical practice improvement methodology, we were able to identify, define and diagnose the problem. Using solutions and interventions developed from the identified problems; we have achieved some early success in improving the care that we deliver to Aboriginal patients. Such success includes a reduction in readmission rates by 4.5% and a higher reported confidence and satisfaction with the health service provided.

Contact

Annie Orenshaw, Port Macquarie Base Hospital

aorenshaw@ncphn.org.au

Collaborative Community Mental Health Program

Project aim

To support young and older adults in recovery from mental health challenges to find a community of acceptance & belonging, where they can grow in confidence, creativity and job skills, so they can play a full role in society.

Abstract

Participants can choose from a range of activities which help them to grow and develop skills:

(a) Joining the Absolutely Everybody Choir of the School of Hard Knocks Port Macquarie Hastings with volunteer buddies, engaging in social inclusion and disciplined weekly choir rehearsals;

(b) Joining weekly small group narrative sharing sessions in “Moving Forward With Confidence”;

(c) Engaging in a range of experiential courses in the “Life Skills Express program” towards creative expression, job skills and even small businesses of their own; and

(d) Becoming active members of the full program at the Endeavour MH Recovery Clubhouse, where they can be part of a community in psychosocial & vocational development.  

Contact

Dr Robbie Lloyd, Port Macquarie Community College (PMCC) and Endeavour MH Recovery Clubhouse

Robbie.lloyd@skillslinktraining.com.au

Community Pain Management Program

Project aim

Delivering community pain management programs for patients, which will assist them to identify goals, barriers & boundaries, crisis management strategies and self-help routines.

Abstract

North Coast Primary Health Network (NCPHN) Quality and Innovation Directorate and the After Hours Program are rolling out new models of low intensity chronic pain management in General Practices and Allied Health across the NCPHN footprint to improve the ability of people living with noncomplex chronic pain, to manage their pain using a proven skills based approach.

The scope of the project aims to improve the ability of people living with noncomplex chronic pain to manage their pain, using a skills-based approach. In doing so it will also improve health literacy, physical and mental wellbeing, and a potential reduction in hospital presentations. The project will be providing clinicians with training and supervised workshops to practice current chronic pain strategies and pain management treatment skills that will benefit patient outcomes as well as building workforce development and capacity.

NCPHN is providing the program which uses a low intensity program developed by the Agency for Clinical Innovation as the basis of the program.  Data evaluation will be provided by University of Wollongong, with additional mentoring and support to be provided by the Northern Local Health District Specialist Pain Clinic and Royal North Shore Hospital (RNSH) Pain Clinic. Finally General practice GPs RNs and allied health will provide programs in Mullumbimby and Kingscliff, while Allied health clinicians from Port Macquarie, Wauchope, Kempsey, Coffs Harbour, Grafton, Mullumbimby and Murwillumbah will provide the program in their locations.

In this way this multidisciplinary team is working together to improving access to chronic pain management programs in local communities which supports the easier access to health care and reduces health inequity, particularly around transport to health care programs.

Contact

Diana Anderson, NCPHN

danderson@ncphn.org.au

Community Rehab

Project aim

To address increasing demand for accessible and effective Alcohol and Other Drugs (AOD) treatment services in the Northern Rivers area of NSW through the provision of a six week day rehabilitation service across three regional localities.

Abstract

Northern Rivers Primary Health Network data (NCPHN, 2016) confirms that the region suffers from a chronic lack of accessible and effective AOD treatment services.  Current services are overextended and don’t provide a treatment option for people who require more intensive treatment than traditional outreach services, but whose financial, personal and professional circumstances prevent access to longer term residential services.  The Buttery’s Community Rehabilitation (CORE) Program offers an evidence based, mid-intensity day time intervention over six weeks that creatively addresses consumer barriers to treatment while also providing intensive individually tailored aftercare support to reduce relapse rates.

Contact

Krystian Gruft, The Buttery

Krystian@buttery.org.au

 

Community Voices

Project aim

Empower small and isolated communities to improve their health, well-being and resilience, through a range of community engagement activities.

Abstract

The Community Voices program facilitates empowerment and connecting the voices of isolated small communities across the North Coast of NSW.  Established in 2014, the program’s vision is to build the capacity of small and isolated communities to become resilient, healthy communities.  

Since its inception in 2014, the program has continued to evolve due to continual reflection on process and outcomes.  Working closely and consistently with community members has resulted in meaningful partnerships enabling the implementation of person-centred approaches to improving health and social outcomes for each small community in the program. 

Community conversations and consumer stories are mediums used for gaining a deep understanding of small communities including their strengths, concerns and aspirations.  Innovative local solutions are explored and implemented by the community enabling local commitment and sustainable outcomes.  The shared successes associated with partnering with small communities should be celebrated through the Primary Health Care Excellence Awards 2017.

Contact

Anne-Maree Parry, NCPHN

aparry@ncphn.org.au

End of Life Care Project

Project aim

The End of Life Care (EOLC) project aims to improve the recognition and management of people at the end of their lives. Firstly, a multifaceted framework guides patient management in the last days of life (with 100% of eligible patients using the Last Days of Life toolkit by September 2017). Secondly the project delivers differing education modalities to aid clinicians’ recognition and skill set to discuss end of life issues. Lastly, it engages with the community to instill confidence in their end of life choices.      

Essential element number one:  Dying is a normal part of life and a human experience, not just a biological or medical event.  (National Consensus Statement Essential Elements for Safe and High Quality End of Life Care, 2015.

Abstract

This project acknowledges the Local Health District philosophy of continuous improvement and the specific need to improve our end of life care. Over the last two years there have been system improvements made via two Root Cause Analyses relating to End of Life Care. The Richmond network has recognised this and has been proactive in improvement of End of Life Care. There has been the formation of the End of Life Committee in March 2016 and recruitment of an End of life Care Project Officer in October 2016. 

The EOLC Project has made great achievements. The Last Days of Life toolkit (LDOL) – a NSW Clinical Excellence Commission (CEC) initiative – was implemented in Lismore Base Hospital (LBH) with great success. It was introduced at LBH initially as a pilot – this proved to be very successful – and has now been re-released post pilot result improvements.

In combination with the toolkit implementation there has been extensive education organized in this short time. This includes an education evening forum (please see attached flyer), and now the rolling monthly education sessions to aid clinicians in having end of life conversations, which will be conducted across our LHD footprint (please see flyer attached).  There is also a monthly EOL Project newsletter to advise of progress and maintain dialogue with all clinicians (please see attached newsletter). All of the events organized for the EOL Project have been filled to capacity consistently – signaling strong clinician interest and engagement with the EOLC project and its aims. 

As demonstrated throughout this document, the project is already realising positive outcomes. Moreover, with improvements in assessment and care of patients in the acute care setting, the flow on affect to the rest of the community will also be beneficial.

Essential element number seven: Safe and high-quality end-of-life care requires the availability of appropriately qualified, skilled and experienced interdisciplinary teams. (National Consensus Statement Essential Elements for Safe and High Quality End of Life Care, 2015)

Contact

Anna Law, Integrated Care

Anna.Law@ncahs.health.nsw.gov.au

Falls Prevention Program

Project aim

Feros Care developed and implemented an innovative “Falls Prevention Program” by focusing on strength and balance based activities to reduce the number of falls among seniors living in residential care.

Abstract

Feros Care commenced the Program in 2016 at one of its residential care villages. The program involved participants doing 50 hours of exercise over 6 months including progressive gym based resistance training and high level balance work. The program deserves an award because it is the only program to date that has applied this level of exercise in a residential care setting with people of an advanced mean age. There are no other residential aged care facilities in northern New South Wales that offer this type of gym equipment and the associated programs for their residents. 

Contact

Jennene Buckley, Feros Care

JenneneBuckley@feroscare.com.au

Kulai Gamumbi Ngarri Playgroup

Project aim

A partnership was formed between Kulai Playgroup and the Coffs Harbour Aboriginal Maternal & Infant Health Service (AMIHS) to provide child developmental support, education and referral access for Aboriginal children and their families.

Abstract

We commenced a partnership with Kulai Playgroup to provide child developmental support, education and referral access for Aboriginal children and families. Previously, engagement with Aboriginal families was difficult. Now a multidisciplinary team approach involving our staff from Aboriginal Maternal & Infant Health Service including the Aboriginal Family Support Worker, Aboriginal Health Worker and Midwife, and other staff from Health including Quit For New Life (smoking cessation program for Aboriginal women and families), Speech Therapist and Occupational Therapist attend.

We partner with other services - Child & Family Health Nurse and Health Worker from Galambila Aboriginal Medical Service &  Beyond Empathy NGO who conduct art based activities. The program has a monthly education topic where we invite guest speakers such as Cancer Council – Sunsafe,  NSW Fire & Rescue – Fire Safety & Dental Services.

Contact

Kate Skinner

Mid North Coast Local Health District Aboriginal Maternal Infant Health Service (AMIHS)

Kate.Skinner@ncahs.health.nsw.gov.au

NAAICC: Coordinated health and social care in action

Project aim

The aim of the Nambucca Area Aboriginal Integrated Care Committee (NAAICC) is to conduct a forum for health and social care providers to discuss Aboriginal chronic care clients who are at risk of poor health outcomes due to a lack of coordinated care.

Abstract

The NAAICC was designed by community and health workforce members to meet the needs of a targeted vulnerable sector of the Nambucca community. The group meets once a month to discuss vulnerable Aboriginal patients, looking for overlaps and gaps in service with the intent of developing strategies to address client’s needs with disregard to traditional barriers across their care settings. Meetings have resulted in agencies being more collaborative and most significantly patients are placed firmly at the center of discussion.  Clients are becoming empowered to be partners in their care aided through the collaborative local health and social care provider group working together to provide coordinated care. Support is based on what is important to the client. An added benefit is that participants are building working relationships that extend beyond the regular meetings.

Contact

Wendy Campbell, Nambucca Valley Integrated Care Initiative

wendy.campbell@ncahs.health.nsw.gov.au

Northern NSW Health Literacy Project

Project aim

The Northern NSW Health Literacy Project aims to empower people to act as partners in their health care and self-manage their own health conditions by improving health communication.

Abstract

More than 60% of Australian adults do not have the level of health literacy needed to understand and act on day to day health information (Australian Bureau of Statistics, 2008). Faced with a growing and aging population and increasing rates of chronic and complex conditions, health services in Northern NSW need to find innovative ways to continue to provide quality, safe, effective and efficient health care. Low health literacy is linked to poorer health status, low use of preventive health services and higher rates of potentially preventable hospitalisation (ACSQHC, 2014). The onus is on health services and health professionals to provide information that is clear, in ways people can access and that empowers people to act as partners in their health care. The NNSW Health Literacy Project is an innovative project that responds to the needs of the community. It aims to improve person-centred care by:

  • Providing consumer health information that is easily understood and supports people’s increased knowledge, empowerment and self-management of their own conditions.
  • Developing the skills and capabilities of the health workforce to improve communication with people in their care.

Contact

Taya Prescott, NNSW LHD & NCPHN

taya.prescott@ncahs.health.nsw.gov.au

School Child Health Check Program

Project aim

To increase enrolment and participation of preschool and school aged Aboriginal children (and their families) who are eligible to receive Health-checks every 9 months at identified at risk communities within the Bulgarr Ngaru Medical Aboriginal Corporation - Richmond Valley (BNMACRV) footprint.

Abstract

In Australia Aboriginal children have worse health outcomes than children who are nonAboriginal.  Aboriginal children who are between the ages of 5-15yrs of ages and generally not seen by a GP unless there is illness or injury.  Many school aged children are not seen frequently enough and health issues such as, speech, dental, nutrition & hearing go unchecked leading to chronic and ongoing health problems and low education attainment. 

Since early 2015 the Binungs (Ears and Didungs (teeth) School Health Program visited over 22 schools in the Richmond Valley area and provided dental examinations, fluoride application and hearing screening and further referral back to the Casino AMS for follow up treatment, proved to be successful increasing enrolment. 

The school health program has since evolved and now uses a multi disciplinary partnership approach utilizing the skill of BNMACRV, North Coast Area Health Service Oral Health Team, the North Coast Primary Health Network (NCPHN) and the Royal Far West health professionals. The aim of the project is to improve Healthcare Access by taking our Child Health Team out into the school setting to provide this service and capture kids that may not be enrolled with an AMS or may not have access to specialist health providers, screen, refer on and follow up.  Through culturally appropriate provision of early intervention and education in the school setting we aim to prevent common progression to childhood diseases.

Contact

Troy Combo, Bulgarr Ngaru Medical Aboriginal Corporation Richmond Valley

tcombo@bnmacrv.com.au

Telehealth for cancer follow up / easy access

Project aim

This project aimed to increase the use of telehealth technologies to improve access to care and care co-ordination for patients experiencing difficulty attending clinics in person.  Improving access was to be achieved through the use of telehealth technologies. Improving care coordination was to be achieved by encouraging greater involvement of the patient’s primary care provider (PCP), typically their GP, in their ongoing care.

Abstract

In order to improve access to care and care coordination for the patients of the Mid North Coast and Northern NSW Cancer Institutes, a telehealth project was initiated. The aim of the project was to utilise telehealth for specialist follow up appointments in order to reduce travel related stress for patients, and to enhance the quality of care by including the GP to a greater extent in the cancer follow up care. This needed to be achieved with existing IT infrastructure and resources, as well as existing administration resources. The project has successfully designed and implemented a telehealth system utilising the video-conferencing functions of the Microsoft Lync software package in order to provide cancer and haematology related specialist appointments to patients who would otherwise have experienced significant difficulty in accessing this care.

Contact

Janice Kilmurray, MNCLHD/Mid North Coast Cancer Institute

Janice.kilmurray@ncahs.health.nsw.gov.au

Welcoming Aboriginal Women: Making Maternity Services Culturally Inclusive Places

Project aim

The aim of this project is to encourage engagement in maternity care during pregnancy and early infancy for Aboriginal women and their families by making maternity services more welcoming and culturally inclusiveness.

Abstract

Maternal and infant mortality rates are significantly higher for Aboriginal mothers and babies, with maternal mortality 2.7 times higher and perinatal death 1.7 times higher than for non-Aboriginal mothers and babies (Ministry of Health, 2015).  Access to antenatal care earlier in pregnancy, increased numbers of antenatal care visits, reduction in prevalence of smoking during the second half of pregnancy and increased immunization rates are well documented strategies for closing the gap in health outcomes for Aboriginal women and babies during pregnancy and early infancy (Ministry of Health, 2015). 

This project engaged a team of local Aboriginal women and health professionals working in Aboriginal specific maternity services to work together to investigate the experience of Aboriginal women using maternity services in the Northern NSW Local Health District (LHD).  The result was a series of innovative and creative strategies designed to increase access to maternity care by making maternity services welcoming and culturally inclusive for Aboriginal women and their families. A local Aboriginal woman with extensive experience in Aboriginal Health was employed as project officer to lead the project.

Contact

 Ellie Saberi, Northern NSW LHD NSW Health

Ellie.Saberi@ncahs.health.nsw.gov.au

Category 4 - Promoting Healthy Living

BNMAC Fruit and Vegetable Program

Project aim

To improve the health and wellbeing of Indigenous children identified with health challenges associated with poor diet.

Abstract

The need for the Bulgarr Ngaru Medical Aboriginal Corporation Richmond Valley (BNMACRV) Fruit and Veg Program was identified by clinicians at the Aboriginal Medical Service when health problems were identified in pregnant women, pre-school and school aged children. 

The current draft of the National Strategic Framework on Chronic Conditions, developed by the Australian Government, has prevention of Chronic Disease as one of its 2 core objectives. To meet this objective, it suggests addressing several strategic priority areas, including risk reduction during critical stages of life such as pregnancy and early childhood with timely and appropriate detection of the precursors to the chronic disease. Our Program demonstrates precisely these actions and so, as a public health initiative, is perfectly in line with the national thinking in efforts to prevent escalating rates of chronic diseases in Australia.

The project was initially pioneered by Grafton BNMAC as a study to determine health outcomes for indigenous children when increasing fruit and vegetable intake. The BNMACRV Nutritionist has been working on, and had a vision, about creating a program for Richmond Valley families for the past few years. It came to fruition when the organisation “Housing for Health” approached BNMACRV with funding to address healthy eating for indigenous children.  Initial targets were to supply fruit and vegetables on a weekly basis to 20 families in 5 communities for 12 months. The program was able expand to include 39 families. Due to the successful delivery of the fruit and vegetable program we have secured additional funding within BNMACRV and Housing for Health for the next 12 months, -  that will allow expansion to 50 families.   

All produce was sourced from a local wholesale green grocer to ensure a high value for money on fresh seasonal produce. Research on availability of fresh produce in each local community demonstrated that variety was limited and the cost was substantially higher. Due to the success of this program future delivery strategies are being established that will benefit the broader community.  We are contracting a local company to both deliver the fruit and vegetable boxes to participating families and offer a Vege Van for other community members to buy produce.

Contact

Anne Criner, Bulgarr Ngaru Medical Aboriginal Corporation

acriner@bnmacrv.com.au

 

Dementia services mapping / Dementia health literacy project

Project aim

To facilitate accessibility to local and current dementia related information for the Far North and Mid North Coast NSW; supporting informed decision making for people with dementia, their support networks, clinicians, service providers and the wider general community.

Abstract

The Tweed Valley, along with other dementia “hot spots” on the Far North and Mid North Coasts, has one of the highest prevalence of dementia in NSW. Consultations in the areas of aged care and dementia showed a limited understanding of local services and how to access those services. It was identified that two priority areas for action were service mapping and health literacy. 

Current dementia services have been mapped by project officers for inclusion in the development of a Dementia Toolkit for the Tweed Valley. Consultation with consumers and their feedback has shaped the Toolkit. People with dementia will feel empowered in managing their health and lifestyle decisions by using this Toolkit. Their families/carers, clinicians and service providers will access dementia information and local supports online (and in hard copy form) for an all-inclusive easy point of access.

Contact

Grace Burgess, NCPHN

gburgess@ncphn.org.au

 

Live well now – a website promoting healthy lifestyles

Project aim

The aim of the project was to:

  1. a) provide evidence based, practical information to the public on the key health promotion topics of healthy eating, exercise, healthy weight, smoking and risky drinking, and

b) increase referrals to local and state-wide preventive health programs. 

Abstract

We created a user-friendly, publicly-accessible website that provides health information on a range of preventive health issues. It features local photos, programs and services that people can easily book in to. The website is designed to increase health literacy by empowering people to access, understand and act on health information and use services to improve their health and prevent chronic disease.  The result is a dynamic website that has a growing number of visitors per month. Universal (ie not targeted) preventive programs and services provided by health promotion are consistently reaching target enrolments. 

Contact

Jillian Adams, Northern NSW Local Health District

Jillian.adams@ncahs.health.nsw.gov.au

 

Northern Rivers Vaccination Supporters

Project aim

The Northern Rivers Vaccination Supporters (NRVS) are a community group working to increase vaccination rates.

Abstract

Since forming in 2013, we have gained significant insight into why vaccine hesitancy and refusal is so common in this area, developed a culturally appropriate approach to help people make informed decisions about vaccinating, and supported those who choose to vaccinate in a region where speaking out in favour of vaccination carries the risk of being ostracised.

Contact

Rachel Heap, Northern Rivers Vaccination Supporters

rachelheap@hotmail.com

 

Northern NSW Aboriginal Women’s Heart Disease Awareness

Project aim

Conduct a series of Heart Health Awareness Workshops for Aboriginal Women in Northern NSW to raise awareness of the risk factors for heart disease. (The workshops will be conducted at 7 sites; - Tweed Heads, Ballina, Maclean, Grafton, Lismore, Casino and Kyogle)

Abstract

Cardiovascular disease is the leading cause of death for Aboriginal people, who experience and die from cardiovascular disease at much higher rates than other Australians. Heart disease is an issue for Aboriginal women who are at least three times more likely to be hospitalised due to heart disease than non-Aboriginal and Torres Strait Islander women. The goal of this project is to develop Aboriginal women as heart health champions to advocate and develop their own community health living awareness. Between 14th March 2017 and 1st August 2017, 3 workshops will target 200 women. Currently two (2) workshops have been conducted and another one will occur during the second half of 2017. Following attendance at the second workshops the women are refer and encourage to participant in the Aboriginal Healthy Lifestyle Program occurring in their area. This attendance is aimed at increasing sustained life changes.  

 

Program objectives are. 

  1. Create a comfortable environment for women to learn and ask questions to recognise the importance of heart disease in a program facilitated within their own communities
  2. Raises awareness of the risk factors/ signs and symptoms of Heart Disease and what a heart health check means through education (Clinicians/ Dietitian/ EP/ resources (Heart Foundation)/ patient stories/ Aboriginal specific videos (ACI)
  3. Importance of healthy eating and menu planning by assisting women to identify food types/meals that they are able to incorporate into sustainable everyday living.
  4. Using Smokerlyser to identify risk of passive smoking amongst the non-smokers within a family
  5. Exercise in a safe environment and have a planned exercise program that addresses their individual requirements and is personally designed for their home use after the program (by Accredited Exercise Physiologist).

Contact

Anthony Franks, Northern NSW Local Health District

Anthony.franks@ncahs.health.nsw.gov.au

 

Northside Health Hub

Project aim

To create a hub of health information and education at Northside Health. Empowering our patients and the community, to take ownership of their health and wellbeing.

Abstract

According to the Australian Institute of Health and Welfare, optimal health requires a two-pronged approach: prevention and treatment. On the one hand we can seek to reduce the likelihood of a disease or disorder occurring, or at least slow down its advancement. On the other hand we need to treat people as effectively as possible when they do become ill.

Northside Health has taken this very wisdom and put it onto action in the following ways:

  • Providing free health promotion events and resources to patients and the wider community
  • Setting up PDSA’s that invite patients to be proactive with the management of their chronic conditions such as Asthma and Diabetes
  • Continuing to provide optimal care to our acutely unwell patients.

Contact

Karen Plumbe, Northside Health

KarenP@northsidehealth.com.au

 

Nymboida Community – Working Together

Project aim

Provision of a peaceful and environmentally friendly location for all to enjoy healthy outdoor recreation and social interaction.

Abstract

This project reflects a collaboration of a small rural community to foster a safe serene setting that enables persons of all walks of life to appreciate nature in a bush landscape.  The project facilitates physical comfort owing to unique recreational aspects directed towards volunteers, members, employees and clients as well as presenting a site which allows for relaxation to obtain a spiritual and mental wellbeing.

Contact

Stephen Hall, Nymboida Camping and Canoeing

yolsta@yahoo.com.au

 

The Life of Byron - Conversations with the Elders

Project aim

To improve the health and wellbeing of ageing people living within the Byron Shire footprint. 

Abstract

The Byron Bay Community Association is a not for profit organisation operating from a purpose built Community Center (BCC) in the business district of Byron Bay. 

With very little ongoing local, state or federal government support it runs a number of programs specifically tailored to community’s needs. Between 2012 and 2017 the Association successfully secured two grants, a major Commonwealth grant, ‘Creative Connections - Community Program Grant’ (timeframe 2012-2015), and a smaller allocation from the ‘Foundation for Rural and Regional Renewal’. The major grant had eight (8) key objectives, all relating to older people and healthy ageing- e.g. ‘Foster a sense of belonging and community connection for older people’. This larger grant was allocated to a variety of innovative projects, many of which continue today, e.g., weekly seniors drumming, singing and yoga classes. ‘The Digital Life Stories’ was a significant activity and is available for all to access on the World Wide Web. 

The smaller grant, (timeframe 2016-2017), allocated under the Caring for Ageing Rural Australians banner, is titled ‘The Life Journey Project’. The aim was to improve the quality of life of people living with dementia. Like the larger grant, aspects of the project are sustained and continue in the community/Residential Aged Care facilities today. Both grants were aggregated under an umbrella title of “Healthy Ageing”. 

Contact

Cat Seddon

Byron Community Association

communityservices@byroncentre.com.au