The One Good Community General Practice Program...TH ON GOO CONT2 GN PCTC GNTS POG One Good Community General Practice Program (OGC GP Program) recognises that general practice is

THE ONE GOOD COMMUNITY GENERAL PRACTICE GRANTS PROGRAM

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The One GoodCommunity GeneralPractice Program

Gippsland Primary Health Network

www.gphn.org.au


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One Good Community General Practice Program (OGC GP Program) recognises that general practice is the cornerstone of healthcare. At a glance:

• People are living longer with 22.4 per cent of the Gippsland population over 65 are reported to visit a general practitioner over 10 times per year.

• Preventable hospitalisations and avoidable presentations to emergency departments continue to rise; in the last 12 months there were 11,004 preventable hospitalisations.

• Forty per cent of general practitioner consultations related to the management of at least one chronic health problem.

• In Gippsland, the most common chronic conditions likely to result in hospitalisation include; cardiac, respiratory, diabetes and mental health.

• General practitioners reporting mental health as the most common reason for patient visits, 62 per cent.

• Across Gippsland, 18.7 per cent of adults’ report being socially isolated.

Building an integrated system of health that considers multiple, interconnected factors across the lifespan inclusive of community, carers and consumers is critical. Digital health enables the building of a contemporary, quality health system that is outcomes-focused and values-based.

By embedding the use of digital health tools and technologies by general practice the OGC GP Program seeks to encourage general practice to shift models of care to impact positively on the health and wellbeing of community, carers and family who care for people living with chronic, complex health and mental health.

Digital health tools and technologies can improve quality through measures such as monitoring chronic conditions more effectively to avoid acute events, increase adherence to best practices, increase early detection and screening of disease, improve clinical decisions, and promote healthier behaviors.

The One Good Community General Practice Program


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To support general practice, Gippsland PHN has developed the OGC GP Program which includes the: • Digital Health Maturity Assessment. This is a great way for general practices in Gippsland to

determine their level of digital maturity and support the planning of digital health improvement activities over time.

• One Good Community General Practice Digital Health Toolbox. This includes a range of information and resources available to support general practices to better identify and understand how digital technologies can be used within practices to improve quality, safety, accessibility, transparency, efficiency and patient outcomes.

• One Good Community General Practice Grants. These are one-off grants up to $42,500 for Gippsland general practices to establish sustainable models of care that produce positive health outcomes using digital health tools and technologies.

The Gippsland PHN OGC GP Program is guided by a set of principles: • QUALITY AND SAFETY: Engage the patient in the care they need using digital technologies in an accessible,

safe and effective manner.

• QUALITY IMPROVEMENT: Drive quality improvement using digital tools and technologies to promote optimal patient experience and outcomes.

• DRIVE DIGITAL ADVANCEMENT: Through the introduction and maintenance of innovative digital and population health resources and tools to support general practices advance to the next digital health maturity level.

• PLAN FOR SUSTAINABILITY: Establish new workflows and ensure the entire workforce has the digital skills and knowledge to achieve long term sustainable improvements in delivery of quality care.

• DELIVER PATIENT-CENTRED CARE THAT CONSIDERS SOCIAL DETERMINANTS OF HEALTH: By offering patient-centred goals setting and care coordination that facilitates service access and monitoring of activities between providers to facilitate self-management, appropriate care, health outcomes and greater efficiency.


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Improving care delivery models by embedding digital innovations

Digital solutions such as Secure Messaging and My Health Record to facilitate a more seamless exchange information and data between patient and providers.

Integrating and embedding patient care pathways across care settings.

Digital health technologies to enable healthcare professionals to take advantage of easy to use systems to improve both personal and team efficiency and effectiveness.

The use of digital tools to enhance clinical decision making, monitor treatment protocols and potentially reduce variability and increase adherence to good clinical practice.

Apply before 26 October 2020!Gippsland Primary Health Network (Gippsland PHN) is offering one-off grants up to $42,500 to eligible Gippsland general practices to establish sustainable models of care that produce positive health outcomes using digital health tools and technologies.

There are three levels of funding available. The level of funding being applied for will determine the level of detail and information required as part of the application process.

Funding is available in three tiers: • Level 1: Foundational $25,000 • Level 2: Intermediate $35,000 • Level 3: Advanced $42,500

The grants are now open and close on 26 October 2020.

If you would like more information or to discuss your application, please email Gippsland PHN

Click here to complete the Online Application Form

mailto:Digital.Health%40gphn.org.au?subject=

http://gphn.foliogrc.com/contracts/new?contract_template=80&token=t5HyU_LtpL74xVEdcr1z


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Applying for a OGC GP grantGippsland PHN is seeking applications from general practices committed to embedding digital health tools and technologies to deliver quality care that impact patient outcomes by:

• Establishing models of care that support comprehensive, better coordinated, integrated and team-based care.

• Enabling general practice to implement models of care that support patients at high risk of hospitalisation, have or are at risk of having a chronic, complex including mental health condition.

• Increasing opportunity for general practitioners and their practice teams to provide preventative care, early diagnosis and early treatment of these health conditions by applying a stepped model of care.

• Increasing opportunity for general practice to enhance quality improvement activities in line with the Practice Incentives Program Quality Improvement Incentive (PIP QI) Program.

• Increasing digital health maturity of general practice in Gippsland.

Examples of the types of activities that will be supported by these grants: • Learning and development activities that increase

practice capacity and build a culture that embraces digital health to deliver improved patient outcomes.

• Improvement activities that aim to reduce hospitalisation through the earlier identification and management of patients who are at high risk.

• Innovative solutions that increase access to digital technologies for the most vulnerable patients with chronic health conditions, including mental health.

• Strategies for improving care coordination and team-based care through the use of digital tools and technologies.

• Activities aimed at the delivery of outcomes-focused and values-based patient care.

• Strategies that support the introduction of remote monitoring technologies and social prescribing principles in the delivery of models of care.


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Eligibility Criteria

To be eligible for a grant, general practices and Aboriginal Community Controlled Health Organisations (ACCHO) must operate in the Gippsland region and have participated in a Digital Health Maturity Assessment.

If you have not completed a digital health maturity assessment, please email Gippsland PHN to complete the assessment.

Successful applicants must be willing to submit a Digital Capability Improvement Plan, interim and final report and participate in the Digital Health Maturity Assessment on completion of the final report.

If a general practice or ACCHO operates multiple sites, only one application can be submitted.

Successful applicants must be willing to submit a Digital Capability Improvement Plan, interim and final report and participate in the Digital Health Maturity Assessment on completion of the final report.

Pre-requisites: The applicant; • Operates within the Gippsland PHN region.

• Has participated in the Gippsland PHN Digital Health Maturity Assessment.

• Holds accreditation against the Royal Australian College of General Practitioners (RACGP) Standards for General Practice 5th Edition.

• Has an Australian Business Number (ABN).

• Must ensure that all general and nurse practitioners have the required professional indemnity insurance cover.

• Declares any perceived or actual conflict of interest.

• Meets the evaluation criteria as outlined in the next section.

Activities outside of scope include: • Existing staff or new positions.

• C osts associated with business as usual (for example, internet).


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Evaluation Criteria All applicants are required to demonstrate the following criteria: • An understanding of the OGC GP program guiding

principles.

• Outline how your practice plans to advance your practice’s digital health maturity.

• Establish how your practice will introduce and embed digital and population health resources and tools.

• Identify how your practice plans to drive sustainable workflows that promote digital health.

• Develop a proposed plan for how your practice will drive sustainable workforce through skills and knowledge development.

In addition, Level 2 Intermediate and Level 3 Advanced general practice are required to demonstrate the following criteria: • Outline how the practice will integrate care

coordination and patient monitoring activities that facilitate self-management.

• Demonstrate a commitment to patient centered goal setting and facilitating access to services for the care of the patient, their careers and family for a defined episode of care.

Evaluation Criterion Level 1 Foundational

Level 2 Intermediate

Level 3 Advanced

Does the application demonstrate an understanding of the guiding principles?

1. Quality and Safety

2. Quality Improvement

3. Drive digital advancement

4. Plan for sustainability

5. Deliver patient-centred care that addresses social determinants of health

20% 20% 20%

Has the applicant demonstrated how the practice plans to use the funds to advance its digital health maturity/ readiness?

30% 15% 10%

Has the applicant demonstrated how their practice will introduce and embed digital and population health resources and tools in daily practice life?

25% 15% 10%

Has the applicant outlined how the practice will drive sustainable workforce through skills and knowledge development?

25% 20% 20%

Has the applicant demonstrated how the practice will integrate care coordination and patient monitoring activities that facilitate self-management?

N/A 20% 20%

Has the applicant demonstrated a commitment to patient centred goal setting and facilitating access to services for the care of the patient, their carers and family for a defined episode of care?

N/A 10% 20%

FINAL SCORE /10

If you meet the pre-requites and have considered how your practice will integrate

and embed digital health, click here to complete the Online Application Form.

http://gphn.foliogrc.com/contracts/new?contract_template=80&token=t5HyU_LtpL74xVEdcr1z


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General Conditions

By submitting an application, the person or organisation agrees that it is bound by these conditions:

• To submit all documents as required by Gippsland PHN.

• That all submitted application documents become the property of Gippsland PHN upon submission.

• To keep submission documents succinct and free from any unnecessary information.

• That all information in the submission is accurate and complete.

• That it will keep confidential any information provided by Gippsland PHN in connection with the application.

• That it will make any enquiries relating to the application process only through the contact details provided.

• Not to reproduce any Gippsland PHN documents (or any part of them) except where necessary for preparation and submission of its application.

• That pursuant to the Privacy Act 1988 (Commonwealth), it will be bound by the Privacy Principles and any applicable Code of Practice with respect to any act done or practice engaged in by the person or organisation in connection with this submission process in the same way and to the same extent as Gippsland PHN would have been bound in respect of that act or practice had it been directly done or engaged in by Gippsland PHN.

• To licence Gippsland PHN to use and reproduce the whole or any portion of the application documents for evaluation, contract negotiation and audit.

Gippsland PHN rights

Notwithstanding anything else in this application guidance document, and without limiting its rights at law or otherwise, Gippsland PHN reserves the right, at its absolute discretion at any time, to:

• aggregate or disaggregate any submission;

• cease to proceed with, or suspend the One Good Community General Practice Program Grants;

• alter the structure and/or the timing of the One Good Community General Practice Program Grants;

• vary or extend any time or date specified in this Specifications and Guidance document;

• terminate the participation of any person or organisation in the One Good Community General Practice Program Grants;

• require any person or organisation submitting a proposal to provide additional information or clarification;

• reject any proposal received; and

• reject any proposal that does not comply with the requirements of this specification document.

For more information click here

http://www.gphn.org.au/programs/good-community-gp-grants


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The OGC GP Digital Health Toolbox

The Digital Health Toolbox is a collection of digital tools, technologies and resources available to support general practices to better identify and understand how digital technologies can be used within practices to improve quality, safety, accessibility, transparency, efficiency and patient outcomes.

POLAR (POpulation Level Analysis and Reporting)POLAR GP is an ‘in practice’ software product for General Practitioners, Practice Managers and other staff to use within their practice to support internal operations, patient-centred care, quality improvement and business development.

Filters can be easily added or removed by clicking on the charts and tables across multiple tabs. For example, practices can identify at-risk patients on a range of clinical indicators, audit appropriate medications and immunisations, track patient and practitioner outcomes, improve data quality and pinpoint business development opportunities.

The POLAR Hospitalisation Risk Report allows general practices to drill down to specific risk category filters to assist with patient care. The report uses calculations to rank patients as low, medium, high or at urgent risk of hospitalisation within the next 12 months.

For more information visit the OGC GP Digital Health Toolbox

My Health RecordMy Health Record provides a platform for a holistic approach, tailored advice and better care coordination. Its use supports healthcare teams in achieving a common goal, optimum health outcomes for patients especially those with chronic and complex medical conditions.

Providing a more complete picture of patients’ health through timely access to their key health information enables safer care and assists you in making better clinical decisions. My Health Record helps you to tailor your advice to patients based on relevant and recent information, support continuity of patient care and inter-professional collaboration.


http://www.gphn.org.au




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Gippsland HealthPathways HealthPathways Gippsland is an online portal, designed to be used by health professionals at the point of care. Each pathway provides clear and concise guidance for the assessment and management of patient with a symptom or condition. Referral information is included in the pathways reflecting the local referral pathways that assist in connecting patients to the right care, at the right at the right place, and with the right healthcare provider.

Each pathway is evidence-informed, reflecting local reality, and aims to preserve clinical autonomy and patient choice.


Digital Health GuideThe Digital Health Guide provides high quality information about mobile health apps, including what capabilities they have, what conditions they are for, what evidence exists to support their claims, and reviews and ratings from health providers enabling provision of advice to patients about what solutions might be appropriate to support their care.


e-Prescribing Electronic prescriptions initiative is a key priority within the National Digital Health Strategy. Electronic prescriptions enable the prescribing, dispensing and claiming of medicines, without the need for a paper prescription. It is not mandatory, allowing prescribers and patients to choose either a paper or electronic prescription.

Existing prescribing and dispensing processes will fundamentally remain unchanged and patients will still be able to fill their prescription from their preferred pharmacy.






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Healthdirect Video Call ServiceHealthdirect Video Call Service is funded by the Commonwealth Department of Health. The platform combines the convenience and benefits of a telephone call with a face-to-face discussion using everyday smart devices (mobile phone, tablet, laptop or computer) and an internet connection.

Healthdirect Video Call provides patients with a single, consistent virtual entry point to a general practice online waiting area. All patients enter the same way, reducing the need for administrative staff to generate a separate link, code or dial-in information for each patient.

Unlike traditional video conferencing, patients do not need an account, special software or dial-in details, which reduces the need for extra resources or systems to support video consulting.


Secure messaging Secure Messaging is a key priority within the National Digital Health Strategy and is a core foundational capability required to enable safe, secure, interoperable and confidential information sharing across all healthcare providers and consumers. Currently, there is a lack of a consistent approach to information exchange across the Australian health sector where it is not possible to send secure messaging from one product to another.


Lifeguard remote patient monitoringThe software platform features a web portal and mobile app for health providers and a mobile app for patients, providing the infrastructure to connect health providers to people isolated in their homes.

Patient Reported Outcome Measures (PROMs) and vital signs for early indication of deterioration of condition (due to COVID-19 and/or complex chronic conditions) can be monitored by a dedicated care team, located in a general practice. Clinical thresholds can be created for patients based on a care plan template defined by a General Practitioner.

If a patient records data outside of the defined clinical thresholds, the care team will be alerted via the platform and action can be taken including contacting the patient (or carer) via telehealth, requesting an appointment with the general practice or directing the patient to urgent care services within a hospital.

This platform will enable general practices to easily monitor any deterioration in several patient’s condition at the same time and support their prioritisation based on acuity of condition for the best use of hospital resources, acting as a funnel into the hospital system, reducing the burden of inappropriate hospitalisation.


LOGO





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Digitally enabled Social Prescribing Social prescribing offers a holistic and person-centered approach to addressing psychosocial wellbeing that is tailored to an individual’s needs. Social Prescribing provides healthcare professionals with non-medical referral options, complimentary to existing clinical treatments to improve health and wellbeing by addressing the social determinants of health.

Social prescribing works by enabling General Practitioners to link patients with social, therapeutic and practical support provided by voluntary and community support organisations in their local area.

Utilising the Kaleidoscope digital solution healthcare professionals are supported in co-designing (between health providers and patients) psychosocial care plans, with measurable goals, tangible actions (i.e. health interventions), social prescriptions and referrals to community organisations.


eLearning Management System A series of Train IT Medical eLearning courses hosted on a unique online Learning Management System (LMS) available to support general practices deliver high quality clinical data and quality improvement processes in general practice.

The series includes:

- Essential Clinical data using BP Premier

- Essential Clinical data using Medical Director

- Database Cleansing using BP Premier

- Database Cleansing using Medical Director

- Quality Improvement & PIP QI including BP premier and POLAR Quality Improvement & PIP QI including Medical Director and POLAR

- My Health Record using BP premier

- My Health Record using Medical Director






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Quality Improvement Toolkit and Practice Incentive Program

Within health care, quality is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. Quality improvement (QI) is defined as a systematic approach that uses specific techniques to improve quality. QI is a continuous activity, as general practices implement changes, there will always be issues to address and challenges to manage. QI encourages practices to learn from their experiences and then use those lessons to shift strategy and try new interventions. This is so practices can continually move incrementally toward their improvement goals.

Continuous Quality Improvement (CQI) involves creating a system to reflect on and refine improvement efforts that aim to provide a better experience of care, improve population health, minimise per capita health care costs and improve the working life of health care providers. This requires practices to create a culture that supports a constant review of the processes and systems to meet these aims.

The Quality Improvement Toolkit is designed to help practices complete QI activities and develop systematic approaches to implementing change.




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Gippsland Primary Health Network www.gphn.org.au

Documents

The One Good Community General Practice Program...TH ON GOO CONT2 GN PCTC GNTS POG One Good Community General Practice Program (OGC GP Program) recognises that general practice is