CC1 - Care Coordination - Implementation

⁠⁠⁠South Eastern Melbourne Primary Health Network (SEMPHN) invites an Expression of Interest (EOI) from general practices across the SEMPHN catchment (Local Government Areas (LGAs) of Bayside, Cardinia, Casey, Frankston, Glen Eira, Greater Dandenong, Kingston, Mornington Peninsula, Port Phillip, and Stonnington) for grant funds to enhance and provide Care Coordination and After Hours (AH) care in General Practice.

SEMPHN is seeking EOIs from general practices to provide the service for a period of 24 months while still working in the current Medicare funding structure.

The primary objective of the initiative is to support the implementation and delivery of care coordination through the Patient Centred Medical Home model of care.

Care coordination supports people’s ability to self-coordinate but also provides dedicated support coordination assistance for those people who require it.

The Care Coordination Implementation activity is for general practices that wish to implement care coordination within their practice. This activity requires the practice to recruit a dedicated care coordinator. Developing and embedding systems and processes for patients and the practice are vital aspects of the role. The care coordinator will be guided by the individual needs of the patient to deliver patient centred comprehensive care. The patient needs may include addressing barriers to engagement, psychosocial issues, and supporting self-management for both patient and family.

To build on the momentum of SEMPHN’s previous investment in Chronic Disease Management and in alignment with the findings from the PwC report, this funding initiative has been developed to further build capacity in General Practice to support comprehensive Care Coordination being one of the main elements of the Chronic Disease Optimal Model of Care Framework.

Essential to the SEMPHN Chronic Disease Model of Care Framework is the provision of comprehensive integrated after hours support for chronic disease patients. Evidence from the Victorian Emergency Data Set suggests that chronic disease patients present to emergency at a higher rate in the AH period for both semi urgent and non-urgent with the presentation rate increasing with age. The PwC report identified service limitations in the after-hours period across the SEMPHN catchment with Sunday coverage a significant catchment wide gap. The availability of general practice was reinforced as a driver of hospital emergency department attendance.

SEMPHN aims to address the current limitations in AH access for chronic disease patients participating in this program by ensuring after hours care arrangements are documented in all care plans, including Anticipatory plans also known as Action plans, are reviewed and discussed with patients/carers/families. Unexpected patient after hours health care needs are then known and can be followed when required.

Refugees not requiring chronic disease care plans must be provided with patient centred care coordination and navigation including knowledge and resources about available, accessible and appropriate health care in the after-hours.

In addition to the above, you may wish to express your interest in delivering the "On-Call GP" AH support service.

Optional after-hours funding: Practices must be successful in this CC1 application to be eligible for this optional AH component.

Further to the AH component mentioned above, practices may express an interest in applying for funding for an ‘On-Call GP" AH support service. Practices must nominate the funding required to provide this service over a 24 month period.

This service must provide the ‘On-Call GP’ AH service to patients on weekdays from 6pm to 11pm and, Saturday, Sundays and Public Holidays from 8am to 6pm or only on Sundays from 8am to 6pm. Preference will be given to those operating ‘On-Call GP’ AH Service on Sundays.

* Note: Practices are not eligible to apply for this optional funding if they are currently receiving the After Hours Incentive Payment (Levels 2 to 5).

Successful practices will be contracted from 1 June 2019 to 30 June 2021. Services will be delivered from 1 June 2019 through to 31 May 2021. A final report will be required by 15 June 2021.