Integrated Team Care Funding Activity Work Plan 2018-2021

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Overview This updated Activity Work Plan covers the period from 1 July 2018 to 30 June 2021. To assist with PHN planning, each new activity nominated in this work plan should be proposed for a period for 12 months.

1. (a) Strategic Vision for Integrated Team Care Funding

The CSAPHN will ensure that eligible patients of both mainstream and Aboriginal Medical Services (AMS) have access to care coordination and appropriate health services to support best health outcomes for patients with Chronic Disease.

CSAPHN and the organisations we commission will apply flexible approaches to ensure Aboriginal and Torres Strait Islander people are able to access high quality care, including through the mainstream health sector.

CSAPHN intends to utilise flexibility to tailor the role and activities of the IHPOs, Outreach Workers and Care Coordinators to suit the needs of communities taking into account the objectives of the ITC activity.

We will support contracted organisations to ensure that Aboriginal and Torres Strait Islander employees are provided with a culturally safe working environment and maintain our responsibility to oversee the ITC workforce across our region, including enablement of professional and peer support.

Throughout the commissioning of services under the ITC Program, CSAPHN will ensure that the following Closing the Gap principals are adhered to including:

1. Priority principle: Programmes and services will contribute to Closing the Gap by meeting the targets agreed by the Council of Australian Governments (COAG) while being appropriate to local needs

2. Indigenous engagement principle: Engagement with Aboriginal and Torres Strait Islander men, women, children and communities will be central to the design and delivery of programmes and services.

3. Sustainability principle: Programmes and services must be considered within a context of a real and practical capacity for resourcing and while the aim is resourcing over an adequate period to meet the COAG targets each activity must include a target for self-sustainability in the local setting.

4. Access principle: Programmes and services should be physically and culturally accessible to Aboriginal and Torres Strait Islander people and recognise the diversity of our near urban, regional and remote needs. Service delivery will be provided according to an equitable spread of resources across our region.

5. Integration principle: There must be collaboration between and within our own organisation and required of government provided services and NGO providers to effectively coordinate programmes and services.

6. Accountability principle: Programmes and services should have regular and transparent performance monitoring, review and evaluation.

CSAPHN will commission service delivery arrangements that most effectively and efficiently meet the needs of patients. Consideration will be given to existing service arrangements including those delivered by the Aboriginal Community Controlled Health Sector.

CSAPHN will continually monitor and review the program for quality improvement, focusing on the performance of the service model in addition to the service provider performance.

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1. (b) Planned activities funded by the Indigenous Australians’ Health Program Schedule for

Integrated Team Care Funding

PHNs must use the table below to outline the activities proposed to be undertaken within the period 2018-2021. These activities will be funded under the IAHP

Schedule for Integrated Team Care.

Proposed Activities - copy and complete the table as many times as necessary to report on each activity

Existing, Modified, or New Activity

Existing Activity - Commission Service Providers to deliver the Integrated Team Care Activity.

Start date of ITC activity as fully commissioned

2 February 2017

Is the PHN working with other organisations and/or pooling resources for ITC? If so, how has this been managed?

Please describe arrangements if the PHN is collaborating or pooling resources with other organisations, including other PHNs. Country SA PHN are working with other organisations including service providers to ensure continuity of care throughout the program. This is being mainly implemented through Care Plans, Discharge plans and referral and follow-up pathways for the patients. As such CSAPHN and Service Providers are working with:

1. The South Australian Health and Medical Research Institute to support the integration of research outcomes into service practices within Care Coordination and Supplementary Services activities.

2. The SA Aboriginal Chronic Disease Consortium to support the integration of health services across the SA health system including the support of shared goals within respective responsibilities and sharing of information surrounding initiatives and issues in the community in the primary health care system and in the tertiary system.

3. Rheumatic Heart Disease (RHD) Australia in terms of common clients and ensuring appropriate access for patients with RHD to MBS (Care Planning) and ITC services. These will be integrated in the form of targets within service agreements.

4. Country Health SA LHNs and LHNs located in Adelaide in terms of common clients and ensure appropriate access for patients with chronic conditions to allied health and specialist services

5. RDWA to ensure services are not overlapped and service gaps are identified and managed.

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6. Country SA PHN will work closely with the Aboriginal Health Council of South Australia to ensure affiliated ACCHOs are well supported

Service provider support of the ITC Activity In response to the service model outlined below, there has been an integration of Care Coordinator and Aboriginal Outreach Worker roles inside clinical care teams associated with the clinics whereby internal referral occurs to maximise patient care delivery and associated support delivered by the Integrated Team Care Activity. i.e. it provides an additional resource to the care teams to maximise the outcomes for patients. In the instances of the dual roles, two staff are employed to deliver 0.5FTE in Integrated Team Care and 0.5 in MBS or other programmed services. In addition, these resources take on external referrals using the same referral system used internally to ensure effective patient tracking occurs with the ITC activity and ensuring mainstream access to the wider region for all the Aboriginal and Torres Strait Islander community in their service locations. This is occurring within the Aboriginal Community Controlled Organisations that have been commissioned.

Service delivery and commissioning arrangements

Currently all roles are within contracted organisations. The recent findings of the ITC Evaluation delivered by Health Policy Analysis and Service Provider reports has created questions surrounding the effectiveness of the four IHPO roles being located within contracted organisations. As such the activities undertaken by IHPOs will undergo increased monitoring and a review will be undertaken of the service model and commissioning arrangements.

A direct commissioning approach is to be undertaken with service providers in the 2018-19. The following service providers will be commissioned to deliver the activity.

Identified Service Provider Service Locations Organisation Type

Ceduna Koonibba Aboriginal Health Service Corporation

Far West; Eyre Peninsula; Ceduna; Yalata; Oak Valley; Scotdesco; Streaky Bay

ACCHO

Port Lincoln Aboriginal Health Service Port Lincoln; Cummins; Tumby Bay; Port Kenny; Port Neil

ACCHO

Country & Outback Health Port Augusta; Nepabunna; Copley; Marree; Peterborough; Hawker; Quorn; Jamestown; Laura; Gladstone; Port Pirie; Crystal Brook, Marree

Mainstream Service

Country & Outback Health Whyalla; Wudinna; Cowell; Lock; Cleve; Woomera; Andamooka

Mainstream Service

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Umoona Tjutagku Health Service Aboriginal Corporation

Coober Pedy; Oodnadatta; Marla Bore ACCHO

Nganampa Health Council Pipalyatjara; Nyapari; Amata; Fregon; Umuwa; Pukatja; Mimili; Iwantja

ACCHO

Pangula Mannamurna Aboriginal Corporation

Mount Gambier; Kingston; Border Town; Naracoorte; Millicent; Keith

ACCHO

Moorundi Aboriginal Community Controlled Health Organisation

Murray Bridge; Raukkan; Mannum; Lameroo; Pinnaroo

ACCHO

Riverland Division of General Practice Network

Berri; Renmark; Loxton; Waikerie; Barmera Mainstream Service

Northern Health Network Clare; Barossa; Gawler; Nuriootpa; Eudunda; Freeling; Kapunda; Riverton; Point Pearce; Moonta; Wallaroo; Ardrossan; Maitland; Warooka

Mainstream Service

The commissioning methods in the future will be determined by the review to be undertaken in 2018-19, which may or may not include a select tender process of the most capable providers locations and will be mindful of the outcomes of the IHPO roles.

Decision framework

The Integrated Team Care Activity in Country SA is delivered in a regional service model. It is delivered through 17 FTEs located in 10 regions and includes:

• 4 FTE Indigenous Health Project Officers

• 3 FTE Care Coordinators

• 3 FTE Aboriginal Outreach Workers

• 7 FTE Dual Roles (Care Coordinator/Aboriginal Outreach Worker Splits)

As Country SA PHN has a large land mass and dispersed population the number of roles has been maximised in order to deliver services to the local populations.

Allocation of funding occurs to a region, rather than to a service provider and is completed through matching of the Aboriginal and Torres Strait Islander population to the number of FTEs required, with local issues and opportunities taken into consideration. The table below provides the basis of the regional allocation of FTEs.

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ITC Regions % of Total Aboriginal Population.

Positions % of Funding

Yorke & Barossa 15% 3.00 16%

Lower Eyre 7% 1.00 6%

Upper Eyre 7% 2.00 10%

Far West 6% 2.00 12%

Flinders 18% 3.00 16%

Coober 7% 1.00 6%

APY 12% 1.00 6%

Murray & Hills 16% 2.00 16%

Riverland 6% 1.00 6%

South East 7% 1.00 6%

From this, the information provided on the region’s ITC allocation is provided to the most capable provider through a direct commissioning process. If, however, the most capable provider does not accept the services or value for money cannot be obtained, the next most appropriate provider is selected.

In all areas the most capable providers are Aboriginal Community Controlled Health Organisations, as they have the largest engagement with the Aboriginal and Torres Strait Islander population. There are two (2) service locations in the Riverland and the Yorke, Mid North, Barossa and Gawler regions which currently do not have an ACCHO operating locally.

Indigenous sector engagement

CSAPHN work directly with each organisation and offer a range of other support and services to ensure a collaborative relationship. This relationship was and is continuing to be developed on an ongoing basis as ACCHOs are recognized as General Practice providers. CSAPHN is able to provide the same level of servicing provided to mainstream general practices in country South Australia. The relationship with each organisation is variable and fluctuates as contractual arrangements change, however ongoing communication exists with all ACCHOS to ensure current and future working engagements are positive and productive. The commitment between CSAPHN and ACCHOS is formalized through various mechanisms which includes Service Agreements, Collaborative Agreements or MOUs.

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• Quarterly meetings: Department of Health (Primary & Aboriginal Health) cross portfolios: Aboriginal Health Policy / Regional Strategies.

• Bi-Monthly meetings: CHSALHN Aboriginal Health Directorate

• Quarterly meetings: CHSALHN Executives

• Quarterly meetings: SAHMRI, Wardliparinga

• Attended AHCSA Member Service CEO Forum

• State-wide Partnership Meeting

• State-wide Aboriginal Mental Health Reference Group

• Ongoing engagement with all ACCHO’s across Country SA PHN

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Decision framework documentation

The decision framework is the same framework provided for the 2016-18 financial years. It is documented.

Description of ITC Activity

Indigenous Health Project Officers (x 4) will deliver the following activities across the CSAPHN service area:

• Delivery of assessment, planning, referral pathways and service mapping to ensure a coordinated approach across the

CSAPHN service area

o Provision of service mapping, referral pathways and other information which incorporates the broader social

service network and health networks to assist care coordinators to deliver on holistic service provision.

o Establish and maintain partnerships with relevant organisations at the local level, including General Practice,

Aboriginal and Torres Strait Islander health organisations, Local Hospital Networks and other local

organisations, and put the necessary protocols and procedures in place to ensure services are delivered in a

culturally appropriate manner.

o Communicate and work with other IHPOs across the regions to work on collaborative projects and ensure overlap of administration and resources does not occur.

o Work across the health sector to ensure access to services and to identify and address service gaps and

overlaps.

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o Development and provision of local resources for care coordinators and Aboriginal outreach workers to assist

in care coordination for clients

• Delivering support to mainstream primary care providers in providing culturally appropriate services including:

o Delivery of RACGP approved cultural competency training

o Undertake activities that improve the cultural competency of mainstream health providers, using appropriate frameworks such as the National Safety and Quality Health Service Standards.

o Assisting mainstream primary care providers to become registered with the PIP: Indigenous Health Incentive.

o Disseminating information to mainstream primary care providers around Aboriginal specific MBS items.

o Education events and workshops to assist mainstream primary care providers in delivering quality services to

Aboriginal people.

o Identifying and addressing barriers faced by Aboriginal and Torres Strait Islander people when accessing

mainstream primary care services, including but not limited to primary care, pharmacy, allied health and

specialists

Note: Utilising underspends CSAPHN will be addressing the shortage of appropriate suppliers of Cultural Awareness Training that are accredited with RACGP. Small grants will be provided to support potential suppliers of the training to become accredited. In addition, regional cultural awareness training will be provided by these providers once accredited.

Note: Utilising underspends CSAPHN will be commissioning the accredited training providers to deliver cultural awareness training in areas of need across the locations.

Note: Utilising underspends CSAPHN will provide grants to General Practices demonstrating a commitment to provision of culturally safe services to Aboriginal and Torres Strait Islander patients to provide welcoming environments (physical) via the commissioning or purchase of Aboriginal artwork.

• Provision of community education around Chronic Diseases and their management and services that can assist including

but not limited to:

o Delivery of health specific events

o Delivery of information workshops based on information from evidence-based research

• Ensure workforce development and peer support occurs for the ITC Activity and workforce.

o Facilitate and coordinate monthly peer support meetings for all regional Care Coordinators and Aboriginal

Outreach Workers. Meetings to include case discussions.

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o Indigenous Health Project Officers are expected to participate in quarterly ITC activity and peer support

meetings, facilitated by CSAPHN.

Note: Utilising underspends CSAPHN will be offering a range of small grants to increase workforce capacity for service delivery staff in the prevention, health promotion and/or management of chronic diseases through financial assistance to access further training, learning and education opportunities. These grants will also enhance and/or add to existing programs.

Care Coordinators (x3) will deliver the following activities:

• To deliver direct client care coordination services in accordance with a care plan developed by a referring GP for eligible

patients including:

o providing appropriate clinical care, consistent with the skills and qualifications of the Care Coordinator;

o arranging the required services outlined in the patient’s care plan, in close consultation with their home

practice;

o Ensuring the client is connected to the wider social network to ensure that a whole of life and whole of health

aspect is undertaken.

o ensuring there are arrangements in place for the patient to get to appointments;

o involving the patient’s family or carer as appropriate;

o assisting the patient to participate in regular reviews by their primary care providers; and

• assisting patients to:

o adhere to treatment regimens - for example, encouraging medication compliance;

o develop chronic condition self-management skills; and

o connect with appropriate community-based services such as those that provide support for daily living.

• Implement, where appropriate, a consistent approach to self-management programs utilising The Flinders Program for

clients with a diagnosed chronic and/or complex condition(s) or at risk of developing one. Delivery of The Flinders

Program to suitably assessed clients to develop collaborative care plans using a patient-centred approach;

• Through the Supplementary Services Funding Pool, the ITC Activity also enables Care Coordinators to assist eligible

patients to access specialist, allied health and other support services in line with their care plan and specified medical

aids they need to manage their condition effectively.

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• Care Coordinators and Aboriginal Outreach Workers are expected to participate in monthly peer support meetings,

facilitated by regional Indigenous Health Project Officers. Meetings to include case discussions.

Aboriginal Outreach Workers (x3) who will:

• provide practical assistance to clients, mainly in the form of travel assistance in accessing health appointments and medications and

• support Care Coordinators and

• support Indigenous Health Project Officers in engaging the Aboriginal community.

Dual Role Care Coordinator and Aboriginal Outreach Workers (x7) who will:

• the role will take on both Care Coordinator and engagement with the community and practical assistance to clients

• and/or the roles may be split in terms of the FTE per role e.g. 0.5FTE Care Coordinator, 0.5FTE Aboriginal Outreach Worker.

In these instances, the Care Coordinators will be qualified Aboriginal Health Workers or Aboriginal Enrolled Nurses or Aboriginal Registered Nurses to ensure that the dual role can be undertaken.

Note: Utilising underspends CSAPHN may seek expressions of interest from current ITC Providers and Aboriginal Community Controlled Health Organisations to increase the Care Coordinator workforce capacity. Any request for proposals will be explicit that due to the short-term nature of this funding activities should not raise community expectations beyond a sustainable level.

CSAPHN Management of Supplementary Services Exceptional Circumstances Funding: CSAPHN will manage supplementary services Exceptional Circumstances in a manner that will reduce the need for DoH approval processes to be overrun and ensure a clinically relevant time frame for approvals. Funding requests will be managed according to the Guidelines for Supplementary Services Funding- CSAPHN ITC Activity in the following ways:

• Where requests are with respect to individuals and the request is in respect to medical aids listed in Care Plans required to effectively manage chronic conditions and co-morbidities, but not currently listed as one of the following categories:

o Assisted Breathing Equipment o Dose Administration Aids o Mobility Aids o Spectacles

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o Blood sugar/ Glucose monitoring equipment o Medical Footwear

The CSAPHN will consider the request and provide appropriate approvals. An example of this type of request includes:

o Catheters to support home dialysis (peritoneal dialysis and home haemodialysis) o Incontinence aids as a result of CKD or other chronic condition o Special dietary requirements.

• Any request regarding Dental Services will not be approved nor forwarded to the DoH for further consideration. It has been made explicitly clear services relating to Dental does not form part of the program.

• Where an ITC Service Provider has made an appeal of a CSAPHN decision it will be forwarded to the DoH for consideration and decision/approval.

• Where requests are made for medical aids for which a set limit has been applied and the cost of the aid is significantly higher than these set limits, for example, Spectacles, these requests will be forwarded to the DoH for approval.

• Where requests are made in respect to individuals, the request is to support the delivery of the care plan and the Supplementary Services funding guidelines are not clear, the request will be forwarded to the DoH for approval.

• Where requests are made in respect to medical aids or services not tied to an individual, but is meeting a service gap so that individuals can access services. Examples of these types of requests include:

o Transport and accommodation of Health Care Providers (e.g. nephrologist) to provide onsite services, rather than multiple individuals being transported to the nearest available service.

o Access to pathology services for CKD in remote areas through the purchase of an ultrasound machine. These requests will be forwarded to the DoH for approval.

All requests are to use the Decision Support Tool for the Integrated Team Care Activity and be accompanied by the recommendations for the assistance from the General Practitioner or Specialists through care plans, and/or assistance for the medical management of chronic conditions.

ITC Workforce

Indicate number of Indigenous Health Project Officers, Care Coordinators and Outreach Workers. Specify which positions will be engaged by the PHN or commissioned organisation(s). If engaged at a commissioned organisation, specify whether it is an AMS* or mainstream primary care service *AMS refers to Indigenous Health Services and Aboriginal Community Controlled Health Services

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ACCHO’S/Identified Service Provider Service Locations FTEs

Ceduna Koonibba Aboriginal Health Service Corporation

Far West; Eyre Peninsula; Ceduna; Yalata; Oak Valley; Scotdesco; Streaky Bay

1.0FTE – CC

1.0FTE – AOW

Port Lincoln Aboriginal Health Service

Port Lincoln; Cummins; Tumby Bay; Port Kenny; Port Neil

1.0FTE–CC/AOW

1.0FTE - IHPO

Country & Outback Health Port Augusta; Nepabunna; Copley; Marree; Peterborough; Hawker; Quorn; Jamestown; Laura; Gladstone; Port Pirie; Crystal Brook, Marree

1.0FTE – CC 1.0FTE –AOW 1.0FTE - IHPO

Country & Outback Health Whyalla; Wudinna; Cowell; Lock; Cleve; Woomera; Andamooka

1.0FTE–CC/AOW

Umoona Tjutagku Health Service Aboriginal Corporation

Coober Pedy; Oodnadatta; Marla Bore 1.0FTE–CC/AOW

Nganampa Health Council Pipalyatjara; Nyapari; Amata; Fregon; Umuwa; Pukatja; Mimili; Iwantja

1.0FTE-CC/AOW

Pangula Mannamurna Aboriginal Corporation

Mount Gambier; Kingston; Border Town; Naracoorte; Millicent; Keith

1.0FTE–CC/AOW

Moorundi Aboriginal Community Controlled Health Organisation

Murray Bridge; Raukkan; Mannum; Lameroo; Pinnaroo 1.0FTE–CC/AOW 1.0FTE - IHPO

Riverland Division of General Practice Network

Berri; Renmark; Loxton; Waikerie; Barmera 1.0FTE–CC/AOW

Northern Health Network Clare; Barossa; Gawler; Nuriootpa; Eudunda; Freeling; Kapunda; Riverton; Point Pearce; Moonta; Wallaroo; Ardrossan; Maitland; Warooka

1.0FTE – CC 1.0FTE – AOW 1.0FTE - IHPO

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In this service delivery model there are 4.0 FTE Indigenous Health Project Officer roles designated to regional areas and operating out of contracted organisations. These areas include:

• IHPO North: Flinders, Port Augusta and Far North.

• IHPO West: Ceduna, Yalata, Oak Valley and Port Lincoln

• IHPO South & East: Riverland and Murraylands, Adelaide Hills, Fleurieu & South East.

• IHPO Central: Clare Valley, Barossa and Yorke Peninsula

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