Summary of COORDINARE’s Baseline
Needs Assessment and Activity Plans 2016-17
OVERALL NEEDS ASSESSMENT AND ACTIVITY PLAN
IDENTIFIED PRIORITY
Chronic disease / potentially preventable hospitalisations
Summary of key issues drawn from the
prioritisation process
COORDINARE’s proposed activities
(including health and service needs analysis)
• Overall high rates of potentially preventable hospital admissions
for chronic conditions
• Relatively high prevalence of chronic conditions across the region
• High rates of avoidable mortality
• Poor coordination of care and lack of associated affordable
timely services to refer on to
• Disproportionate burden of disease on specific populations
• Particularly high prevalence of musculoskeletal disease in
Illawarra Shoalhaven and of respiratory conditions across the
region
• High prevalence of major health risk factors particularly in
Shoalhaven, Shellharbour, Bega Valley, Goulburn Mulwaree and
Eurobodalla Local Government Areas (LGAs)
• Insufficient preventive health activity undertaken in primary care
• Lack of affordable prevention programs and services targeting
risk factors such as physical activity and nutrition
• Increasing rates of vaccine-preventable potentially preventable
hospitalisation
• Issues with medication management contributing to preventable
hospitalisations
• Increasing incidence and mortality rates
✓✓ Through the ACT and Southern NSW HealthPathways and Illawarra Shoalhaven HealthPathways program,
COORDINARE will continue to promote, develop and document Clinical Care and Referral Pathways utilising the
HealthPathways tool. This will ensure GPs are better placed to help patients avoid going to hospital for conditions that
can effectively be managed outside of hospital, improving overall care coordination across the region
✓✓ Through joint planning initiatives with both regional LHDs, COORDINARE will collaboratively focus on locally appropriate
models of integrated and coordinated care, such as transitioning to the next iteration of the Connecting Care model
in the Illawarra-Shoalhaven region; supporting implementation of NSW Health Integration Strategy projects; the
development of joint Integrated Care Strategy (Illawarra Shoalhaven currently under development) and joint analysis
and planning to better understand the profile of potentially preventable hospitalisations at a local level aimed at service
redesign to improve efficiency and effectiveness of chronic disease management
✓✓ In partnership with the University of Wollongong, COORDINARE will continue the Sentinel Practices Data Sourcing
(SPDS) project to enhance the population level monitoring of the prevalence of major chronic conditions and their
associated lifestyle risk factors along with related clinical and service indicators
✓✓ COORDINARE will approach the market to identify evidence based risk factor reduction approaches that are
appropriate for local application, targeting people who are overweight or obese
✓✓ COORDINARE will aim to build research capacity of general practice in our region by supporting a collaboration of GPs
to complete a substantive research project focused on chronic disease management and/or coordination
✓✓ COORDINARE will work with local primary care providers and consumers to identify and implement locally appropriate
initiatives to increase consumers’ capacity to manage their own chronic conditions focusing on the concept of patient
activation
✓✓ Additionally COORDINARE’s workforce development initiatives will be aligned with the priorities of chronic disease/
potentially preventable hospitalisations, healthy ageing, and coordination of care and will focus on translating new
knowledge, skills and attitudes into practice locally and will be led by external clinical experts.
• Relatively high cancer mortality rates
• Limited cancer management services available in rural locations
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IDENTIFIED PRIORITY
Immunisation
Summary of key issues drawn
from the prioritisation process
(including health and service needs analysis)
• Low immunisation rates for all children
aged 24-27 months
• Relatively low immunisation rates for
Aboriginal children at 24-27 months
• Variability in childhood immunisation rates
within particular locations
• Consistently low immunisation rates
in South Coast SA3 (Bega Valley and
Eurobodalla) region for all children 2 and
5 years
COORDINARE’s proposed
activities
✓✓ COORDINARE will work with local
communities to develop and
implement localised prevention
activities. These include, but are not
limited to, increasing immunisation
rates, particularly low immunisation
rates in the South Coast area.
IDENTIFIED PRIORITY
Cancer Screening
Summary of key issues drawn
from the prioritisation process
(including health and service needs analysis)
• Low participation in national cervical cancer
screening program, especially in Wollongong,
Goulburn Mulwaree, Yass and Bombala LGA’s
• Decreasing participation in BreastScreen
• Lack of culturally appropriate support
structures for culturally and linguistically
diverse (CALD) and Aboriginal people to
access screening services
COORDINARE’s proposed
activities
✓✓ COORDINARE will work with local
communities to develop and
implement localised prevention
activities. These include, but are not
limited to, increasing participation
in breast and cervical screening by
CALD and Aboriginal women and will
involve co-designed community level
interventions.
• Strained system capacity to cope with increase
in demand for diagnostic tests following
positive screen
• Low participation in National Bowel Cancer
Screening program
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IDENTIFIED PRIORITY
Aboriginal health
Summary of key issues drawn
from the prioritisation process
(including health and service needs analysis)
• High proportion of Aboriginal population
residing in the catchment
• High level of socio-economic disadvantage
for Aboriginal people compared to nonAboriginal residents
• High rates of potentially preventable
hospitalisations amongst the Aboriginal
population
• Barriers around accessing transport to
attend appointments and preventative
health activities
• Aboriginal Community Controlled Health
Organisations (ACCHOs) identified the need
for increased capacity for data analysis and
evaluation to improve service delivery
• Limited access to culturally appropriate and
gender-specific health and support services
• Limited access to culturally appropriate,
holistic support for cancer patients, survivors
and their families
COORDINARE’s proposed
activities
✓✓ COORDINARE will partner with local
ACCHOs and the university sector to
increase capacity for data analysis,
evaluation and benchmarking.
This will allow shared and improved
understanding of the impact,
improvement opportunities, and
future potential of interventions and
investments. Alongside this, all core
flexible initiatives commissioned
through ACCHOs will contain a
resourced and supported evaluation
component
✓✓ COORDINARE will commission
culturally-appropriate initiatives
for chronic disease prevention and
management, as well as mental health
and drug and alcohol
IDENTIFIED PRIORITY
Ageing
Summary of key issues drawn
from the prioritisation process
(including health and service needs analysis)
• The need to promote healthy ageing: keeping
people well in their communities
• Ageing population and increasing need for end
of life / palliative care
• Limited knowledge around end of life care and
advanced care directives
• Ageing population placing greater demand
on residential aged care facilities (RACFs) and
services
• Increasing frailty of RACF residents
• Navigation and coordination of complex and
changing aged/social care environment
COORDINARE’s proposed
activities
✓✓ COORDINARE will work with
consumers and other stakeholders
to identify the most appropriate
approaches to support healthy
ageing and maximising the
independence and self-care abilities
of older people
✓✓ Additionally COORDINARE’s
workforce development initiatives
will be aligned the healthy ageing
priority and will focus on translating
new knowledge, skills and attitudes
into practice locally and will be led by
external clinical experts.
• Access to suitable primary care during and after
hours
• Limited transport options for the elderly
✓✓ COORDINARE will work with ACCHOs
and mainstream providers to improve
outcomes relating to chronic disease
through coordination of care.
• Disproportionate burden of chronic disease
in the Aboriginal population and high
prevalence of chronic disease risk factors
• Limited uptake of preventive health activity
within primary care
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AFTER HOURS ACTIVITY PLAN
IDENTIFIED PRIORITY
After hours
Summary of key issues drawn from the
prioritisation process
COORDINARE’s proposed activities
(including health and service needs analysis)
• Limited access to after hours services especially in rural areas and
also particularly impacting families with young children, aged care
residents and palliative care patients
COORDINARE’s approach for after hours initiatives will primarily focus on changes in systems and structures, both in
and after hours, to promote improved access to timely primary care across the region.
• Low consumer and provider awareness of available options in the
after hours period
✓✓ access to after hours primary care in rural locations through LHD partnerships
• Capacity in the Shoalhaven region during after hours and seasonal
peaks
• Capacity of aged care facilities to respond appropriately in the after
hours period
• Limited availability of after hours support for individuals and their
families experiencing mental illness
COORDINARE will also support specific initiatives that focus on:
✓✓ equitable access to after hours primary care in rural and urban locations through medical deputising services and
alternatives
✓✓ improving capacity of residential aged care facilities
✓✓ palliative care
✓✓ increasing availability of after hours support for consumers (and their carers) experiencing mental illness and
alcohol and other drug issues
✓✓ promoting after hours options to increase consumer awareness of local options.
• Limited availability of after hours support for individuals and their
families with alcohol and other drug issues
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MENTAL HEALTH ACTIVITY PLAN
IDENTIFIED PRIORITY
Mental health
Summary of key issues drawn from the prioritisation process
(including health and service needs analysis)
• High rates of mental and behavioural disorders and psychological distress amongst adults
• Relatively high rates of suicide and self-harm
• High rates of self-harm amongst 15-24 year olds, especially in the Shoalhaven, Bega Valley, Eurobodalla, Cooma
Monaro, Goulburn Mulwaree LGA’s
• High levels of co-existing conditions including physical health and drug and alcohol in people with complex and
severe mental health
COORDINARE’s proposed activities
COORDINARE will maintain existing services while a Regional Mental
Health and Suicide Prevention Strategy is developed.
From 2017-18, commissioning services will align with our Regional
Strategy and will focus on a stepped care model:
✓✓ low intensity mental health services
✓✓ youth mental health services
• High levels of psychological distress and self-harm in Aboriginal and Torres Strait Islander populations
✓✓ psychological therapies for rural and remote, under-serviced and
/or hard to reach groups
• Limited access and barriers to accessing child and adolescent mental health related services and preventative
services
✓✓ mental health services for people with severe and complex
mental illness including care packages
• Lack of, or poor coordination with, community based mental health services and mental health support services
✓✓ community-based suicide prevention activities
• Inequitable distribution and limited access to psychologists, counsellors, mental health workers and practitioners,
consumer workers and consumer peer workers
✓✓ Aboriginal and Torres Strait Islander mental health services
• Gap in service provision for consumers with moderate to severe mental health issues, or people in crisis
• Limited access to psychiatry services
• Navigation, coordination and case management of health and social services for consumers with chronic and
complex needs
• Limited access to culturally appropriate mental health services for Aboriginal and Torres Strait Islander people
• Lack of preventative mental health services
• Limited access to drug and alcohol rehabilitation services
• Limited access to perinatal and antenatal mental health support services
• Lack of or limited access to suicide support services
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PRIMARY CARE SUPPORT
COORDINARE continues to acknowledge that general practice is the most important pillar of a comprehensive healthcare service system and is most instrumental in keeping the community well,
living independently and out of hospitals. Therefore, in addition to the aforementioned actions, COORDINARE will continue some key functions to support general practices in delivering quality
healthcare especially to those most of at risk of poor health outcomes. These additional activities will be focused on the following themes, which have been guided by the findings of COORDINARE’s
Baseline Needs Assessment:
COORDINARE’s proposed activities
✓✓ COORDINARE will continue to encourage and offer support when required for practices to obtain and maintain accreditation
Building capacity within
primary care
✓✓ Providing access to validated tools such as the University of Queensland’s Primary Care Practice Improvement Tool (PC-PIT), COORDINARE will work with
interested practices to help them assess and identify areas for practice improvement. This tool may also facilitate the transition to the Patient Centred
Medical Home (PCMH) model of care for interested practices
✓✓ Practices will also have access to a range of training and online resources.
Safety and quality improving efficiency and
effectiveness
✓✓ Increasing opportunities and access for general practices to participate in quality improvement initiatives across the region, COORDINARE will work specifically to:
• improve childhood immunisation rates
• improve bowel, breast and cervical cancer screening rates
✓✓ COORDINARE will also support the use of effective local clinical care pathways with the promotion of the two regional HealthPathways programs.
✓✓ COORDINARE will:
Digital health and use of
technology
• continue to promote and support the meaningful use of My Health Record across the region
• look to increase the use of secure messaging technology between health service providers to ensure consumers receive the right care in the right place at the
right time
• seek to expand the use and understanding of available telehealth technology and upskill regional providers involved in coordination of patient care.
Meaningful use of data at
a practice level
Clinical networks /
Clusters
✓✓ Guided by the results and evidence base generated by the Sentinel Practices Data Sourcing (SPDS) project, COORDINARE will provide practices with access to
tools and resources that will improve overall effectiveness of routine primary care consultations using innovative tools.
✓✓ COORDINARE will provide opportunities for all primary health care staff to learn from each other and access relevant professional development. This will be
achieved via the establishment of peer learning networks, professional clusters and targeted learning opportunities that link quality improvement initiatives
with education and peer networking
✓✓ Seeking to strengthen communication pathways between primary and secondary care providers, COORDINARE will work to create linkages for enhanced
care pathways and improved coordination of care.
MORE DETAILS CAN BE FOUND AT:
www.coordinare.org.au/about-us/departmental-documents
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