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Primary Health Branch policy and funding guidelines

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<strong>Primary</strong> <strong>Health</strong> <strong>Branch</strong> <strong>policy</strong> <strong>and</strong> <strong>funding</strong> <strong>guidelines</strong>––2006–07 to 2008–09 (2008–09 update) 13<br />

way forward (DHS, 2006). Community health services<br />

continue to develop <strong>and</strong> refine there service access models<br />

to meet client needs.<br />

Creating a system of care through engaging in partnerships<br />

is the business of every agency. As the scope of service<br />

coordination grows it is important that all agencies funded by<br />

the <strong>Primary</strong> <strong>Health</strong> <strong>Branch</strong> take an active role to improve the<br />

coordination of client care, particularly for those with chronic<br />

<strong>and</strong>/or complex conditions.<br />

To achieve this, all agencies funded by the <strong>Primary</strong> <strong>Health</strong><br />

<strong>Branch</strong> from 2006–07 to 2008–09 are required to:<br />

• actively participate <strong>and</strong> take leadership roles in PCPs<br />

• authorise <strong>and</strong> encourage staff to participate in PCP<br />

activities, where appropriate<br />

• use technology to support good service coordination<br />

practice, including e-referral <strong>and</strong> use of the Human<br />

Services Directory<br />

• provide staff with skills training in using these supporting<br />

technologies<br />

• use software that supports e-referral using the current<br />

version of the Service Coordination Tool Templates (SCTT)<br />

• pursue commercial grade connectivity <strong>and</strong> capacity to<br />

share information using SCTT<br />

• implement the Statewide Service Coordination Practice<br />

Manual (DHS, 2007)<br />

• work with the department to improve service coordination<br />

practice statewide through participation in projects such<br />

as the continuous improvement of the SCTT<br />

• provide feedback to other agencies involved in client care,<br />

including referral acknowledgement<br />

• improve the transfer of client information between agencies<br />

• record GP details on the SCTT<br />

• accept <strong>and</strong> encourage referrals from general practice<br />

using the Victorian statewide Referral Form<br />

• provide feedback to GPs<br />

• embed service coordination <strong>and</strong> integrated health<br />

promotion in agency policies <strong>and</strong> quality improvement<br />

activities<br />

• regularly update agency details in the Human services<br />

directory<br />

• participate in PCP evaluation <strong>and</strong> reporting requirements<br />

including the statewide Service Coordination Survey.<br />

3.5 Integrated chronic disease<br />

management<br />

<strong>Primary</strong> health funded agencies are required to strengthen<br />

their role in providing integrated <strong>and</strong> coordinated services for<br />

people with chronic <strong>and</strong> complex conditions. Agencies<br />

should consider the following areas:<br />

• Workforce development––ensure that staff have the<br />

appropriate knowledge <strong>and</strong> skills to support people with<br />

chronic <strong>and</strong> complex needs.<br />

• Systems change––review agency PPPS to ensure that the<br />

needs of people with chronic <strong>and</strong> complex conditions are<br />

identified <strong>and</strong> responded to in a timely, effective <strong>and</strong><br />

efficient manner. The agency PPPS should be consistent<br />

with the local PCP implementation of the Victorian Service<br />

Coordination Practice Manual (DHS, 2007).<br />

• Increase capacity––where possible, enhance service<br />

delivery responsiveness for people with chronic <strong>and</strong><br />

complex needs.<br />

Strengthening the role of <strong>Primary</strong> <strong>Health</strong> funded agencies in<br />

integrated chronic disease management is a necessary<br />

response to the increasing prevalence of preventable chronic<br />

disease <strong>and</strong> dem<strong>and</strong> pressures on services.<br />

Many <strong>Primary</strong> <strong>Health</strong> funded services across the state see a<br />

large number of people with chronic <strong>and</strong> complex conditions<br />

(approximately 60 per cent of all community health service<br />

registered clients).<br />

Care for people with chronic <strong>and</strong> complex conditions usually<br />

involves numerous health care providers in multiple settings.<br />

To provide this care within an integrated system, providers<br />

must work collaboratively to coordinate <strong>and</strong> plan care <strong>and</strong><br />

services. People with chronic <strong>and</strong> complex conditions need a<br />

responsive person-centred <strong>and</strong> effective system of care that<br />

aims to:<br />

• slow the rate of disease progression while maximising their<br />

health <strong>and</strong> wellbeing within the community<br />

• improve access to quality integrated multidisciplinary care<br />

across the care continuum<br />

• facilitate client <strong>and</strong> carer empowerment through selfmanagement<br />

programs <strong>and</strong> approaches<br />

• promote <strong>and</strong> encourage protective behaviours<br />

• actively engage GPs<br />

• reduce inappropriate dem<strong>and</strong>s on the acute health<br />

care system.

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