Our Priorities
To support the work of Victorian PHNs, the Alliance has three overarching priorities in which we focus our efforts. These are:
- Data and population health
- Care pathways
- Digital health
Alliance Priorities
1. Data and population health
PHNs draw from a range of qualitative and quantitative data sources to build an in-depth understanding of community needs and service capability. As commissioners, the PHNs use this information to inform model of care development, procurement of services, and integration activities.
Examples of key datasets include:
- Aboriginal and Torres Strait Islander Data
- Aged Care Data
- Australian Institute of Health and Welfare Data
- Chronic Disease Data
- Demographic Data
- Digital Health Data
- Health Workforce Data
- Hospital Data
- Immunisation Data
- Medicare Benefits Schedule Data
- Mental Health Data
- Pharmaceutical Benefits Scheme Data
- Population Health Data
- Practice Incentives Program Data
The Victorian PHN Alliance are working together to explore opportunities to enhance the depth of PHN analytics capabilities.
A Review and Environmental Scan was conducted to support developments toward a statewide approach to data and population health. Key activities undertaken included literature review, stakeholder interview (involve government, vendors, academia and key providers), and the conduct of market scanning, and high level data collection and flow mapping. The Victorian Department of Health and Human Services were active partners in this process. A program of work is being implemented to support the findings of the Review and Environmental Scan.
2. Care pathways
PHNs have a role in supporting the primary care workforce, and the adoption of best practice. A key component to supporting the design and implementation of optimal models of care, is the definition and use of agreed localised processes care pathways.
Key efforts include:
Localised care pathways
Localised care pathways are resources designed to help healthcare professionals assess, treat, and manage patients at the point of care by providing information on how to refer to local services and specialists.
Care pathways aim to enhance clinical knowledge and promote best practice care; reduce the number of patients referred to specialist care who could be managed in primary/community care; build collaboration and reduce fragmentation across the health service network, and improve health outcomes.
The development and use of care pathways strengthens understanding of the system in which health professionals work. Care pathways work to:
- Provide evidence-based information regarding conditions and symptoms – Drawn from latest research and clinical guidelines, care pathways provide details on agreed best practice management with links to relevant clinical practice guidelines, key publications and consensus-based resources. What does best practice look like? What are the barriers or enablers to providing best practice care to patients?
- Present localised service and referral information to support appropriate patient referrals – Provide accurate information on local referral options for community and hospital based services and programs, including details about how to refer. What is available in my local area? What do I need to do to ensure I refer correctly? What option is best for my patient? Is there an alternative referral option for my patient other than my local hospital?
- Build collaboration across the sector and aim to identify opportunity for service redesign and partnership opportunities – The development of care pathways is clinician led and collaborative, providing a structure and process for local health professionals and specialist clinicians to collectively articulate agreed criteria for assessment and associated referral requirements. Possible pathway development are embedded within hospital outpatient redesign projects or other service redesign projects. What does the evidence and clinical guidelines say? How do we improve current processes? How can we make referring easier? What can we do to ensure appropriate referrals are being received and how will this impact out outpatient clinic waiting times?
The HealthPathways process
The HealthPathways process is led by GP clinical editors and is designed to involve all those who contribute to patient management. Consumers work alongside the care team. The key steps to the development of localised care pathways are as follows:
Current evidence and best management is reviewed. Issues preventing or enabling the delivery of optimal care to patients are identified with the aim of co-designing solutions.
A clinical working group, including GP clinical editors, specialists, nurses, allied health professionals (e.g. exercise physiology, podiatry) and a wider group of GPs, is developed. These health professionals have input into the development of this work.
When published, the pathways will include clinical information on assessment and management of conditions, useful patient and clinical resources, and local referral information.
Case study – HealthPathways Melbourne: Low Back Pain
Why did we need a HealthPathway for Low Back Pain?
- High volume of patient complaints.
- Changing nature of the evidence base, release of new guidelines, or need for clarity on the model of care.
- Need for quality referrals to expedite first appointment to hospital outpatients.
What did General Practitioners think?
“It’s a really common thing – around 90% of us will have back pain at some point in their life so it’s really important that we get treatment right,” – Dr Debra Wilson, General Practitioner.
What did Specialists think?
“We were sitting here inside Royal Melbourne and all the GPs were out there, and we were just getting flooded with referrals. We said, we’ll help you develop the HealthPathway, because we see that as a way of helping GPs manage back pain within the community and improve their level of care of back pain patients” – Mr John Cunningham, Orthopaedic Surgeon
Case study – Statewide Paediatric HealthPathways
The Victorian PHN Alliance is working with the Victorian Paediatric Clinical Network and the Better Access Subcommittee to translate existing statewide Paediatric Clinical Practice Guidelines (CPGs) into Paediatric HealthPathways. These pathways will empower primary care clinicians to support patients with low complexity, high volume paediatric conditions, and ultimately deliver better, safer care.
The aims of the project are to:
- provide clear and concise best practice state-wide and local referral pathways for paediatric consultations
- reduce inappropriate variation in GP paediatric clinical care through use of HealthPathways in conjunction with GP capacity building
- empower primary care services to better meet the needs of patients, their families and carers
- reduce emergency department presentations of paediatric patients who could be reasonably managed in primary care
- improve partnerships and collaborations between primary, secondary and tertiary providers of paediatric services across the state
- enhance relationships and coordination between primary and tertiary services delivering paediatric care across the state.
To meet these objectives the Statewide Paediatric Pathways Project team ensures ongoing, collaborative consultation with clinicians, experts and associated stakeholders across Victoria throughout the development and implementation of CPG Paediatric HealthPathways. This project will deliver a statewide and local paediatric referral directory through the Gippsland, Melbourne, Murray and Western Victoria HealthPathways sites.
The Statewide Paediatric Pathways Project will create up to 30 pathways and will facilitate and measure the implementation of pathways among the Victorian primary care community.
Victorian State-wide Referral Form
The GP Referral form is a user-friendly resource to support GP referrals to other services, public and private. The referral form provides a standardised mechanism for referral from general practice to health providers including hospital specialist clinics (outpatients). The benefits of using this form are that:
The GP Referral is available as ‘supplied’ in most GP software packages. GPs can simply search for the template in the package they use.
It provides a single referral template which simplifies processes as opposed to using a multitude of service specific referral forms or where a form template does not already exist.
The GP Referral template is the preferred format for GP referrals to Government funded primary care services such as community health. The GP Referral template is also suitable for referrals to hospital outpatient services
Trials have shown that it does not take any more time to generate a referral by using the form compared with traditional referral or letters.
Service Coordination Tool Templates
The Service Coordination Tool Templates (SCTT) are a suite of templates developed to facilitate and support service coordination. The SCTT support the collection and recording of initial contact, initial needs identification, referral and coordinated care planning information in a standardised way.
The Victorian Department of Health and Human Services website contains access to online learning modules, screening tools, and other templates. Software vendors can advise on how to embed SCTT into provider systems.
3. Digital health
The PHNs have a role in digital health which refers to any form of healthcare provision delivered via electronic means. This may include electronic health record, electronic referrals, secure messaging between providers, and telehealth/telemedicine. This includes the use of My Health Record which is a secure online summary of an individual health information.
The Victorian PHN Alliance are working together to support mechanism to enable a coordinated approach to enhancing system connectivity through digital health. This includes a particular focus on eReferral, telehealth, secure messaging and My Health Record adoption across Victoria.