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Integration Project
Program Overview and RationaleIn February 2006, the Council of Australian Governments (COAG) announced a four-year national program called the Australian Better Health Initiative (ABHI). ABHI is a joint Australian, state and territory government program which aims to reduce the prevalence of risk factors for chronic disease, limit the incidence and the impact of these diseases and reduce morbidity and mortality rates.
ABHI’s priority areas include:
• Promoting healthy lifestyles
• Supporting early detection of risk factors and chronic disease
• Supporting lifestyle and risk modification
• Encouraging active patient self management of chronic conditions
• Improving the communication and coordination between care services.
The Division’s ABHI integration project is a joint project between the GP Network Northside (GPNN) - lead agency, the Central Coast Division of General Practice and the Northern Sydney Division of General Practice. All of the divisions fall within the Northern Sydney Central Coast Area Health Service (NSCCAHS). This project is funded under the ABHI priority area Improving the communication and coordination between care services.
The project extends the current work of the three divisions and compliments the planned initiatives of the NSCCAHS. Five public hospitals operate within the service area and each division involved in this project has identified a need to ensure that the primary health care planning provided by GPs is appropriately considered by those hospitals when patients present. Further, when patients are discharged from hospitals their transition back to the primary health care environment is often disjointed, not followed up and ineffective.
Duration of Program and how it operates The project timeframe is from July 2008 – June 2010.
The project focuses on the following areas:
Resource development: Development and dissemination to organisations (including general practices) to improve systems at clinical care level as well as sharing information with stakeholders and broader health network.
Collaboration and Integration: establish strong working relationships with health services and liaise with relevant community health services, health promotion units, and GP Collaboration units within hospitals.
This relationship will assist in the identification of programs and activities that will be relevant to GPs and their patients with chronic illness and will facilitate the transfer of information to GPs about these programs and activities.
Consumer and Carer Involvement: Identifying appropriate prevention & patient self-management issues for the patient and their carers.
Liaison between Acute & Primary Care Providers: liaise with both Acute and Primary Care providers and aim to make care plans available to the medical and nursing staff to assist with admission and discharge planning. At a local level, the project also aims to strengthen capacity of local Aboriginal and Torres Strait Islander population to self-manage chronic disease through collaboration with the Eleanor Duncan Aboriginal Medical Service and other local Aboriginal Community Controlled organisations and appropriate stakeholders.
How the Program benefits GPs and their patientsOverall, the purpose of the project is to improve the management of patients with chronic illness, reduce avoidable hospital admissions and, where patients are admitted to hospital, ensure that the treatment provided is consistent with that patients existing primary health care plan. Current level of Program participation / utilisationThe project aims to involve all GPs, PNs, and various Allied Health Professionals via engagement through various stakeholder meetings, facilitation of improved communication /care pathways between NSCCH Ongoing & Complex Care Services, and general practice, group and/or individual practice visits, and distribution of information and resources through various media avenues.
Co-ordination of the ProgramJennie Sadler
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