Program overview

The Winter Strategy is a program in which COORDINARE will support general practice teams to lead heightened quality and intensity of care, for a group of patients that clinicians think are at high risk of being unstable, very unwell or admitted to hospital during the 2019 flu season. The program overview document is also available for download here.

The program has four phases:

Some ideas to get your practice ready (March):

  • Obtain commitment from practice owner(s): the Winter Strategy needs commitment from the practice owner(s) and staff. In particular, the practice principal needs to be able to ensure protected time for staff to undertake Winter Strategy activities. They also need to be satisfied with arrangements for patient consent, privacy and confidentiality, where pcmh people talking
  • Identify Winter Strategy team members: clarify roles, responsibilities and time frames within the practice’s Winter Strategy team. Communication is key to the success of any new activity. Consideration should be given to how protected time will be arranged, how the team will meet and facilitate internal communication throughout the practice team.
  • Ensure the practice has a sound data quality process: it is strongly recommended that practices are part of COORDINARE’s data quality initiative (Sentinel Practice Data Sourcing program). You may need to undertake data cleansing activities prior to running CAT4 queries to accurately identify target patient groups. For practices not participating in the data quality initiative, please speak with your Health Coordination Consultant to confirm your data quality process.
  • Plan for any potential surge in flu vaccinations or cold and flu exacerbations: how will you manage increased demand? Think about what your system will be, whether there are existing arrangements you can use, and how everyone will know what to do.
  • Plan your model of service delivery: some suggestions are to do it in conjunction with flu vaccination and/or GPMP/TCA review, as they come in for doctor appointments. You may choose to run a nurse led clinic, or you might have another method. It is important to know who will do this and when.
  • Review the evaluation template with your Health Coordination Consultant
  • Identify your 'at risk' patients: COORDINARE will provide a series of CAT4 queries to identify patients at risk of being impacted during the flu season. Clinicians may also choose to target an alternate cohort based on their knowledge of who they think is most at risk of hospitalisation, and who would benefit most. To help practices, COORDINARE will provide a choice of modules that will support clinicians to choose their patient cohort for the Winter Strategy.
  • Ensure practice electronic messaging details are correct and up to date for all relevant clinicians in the LHD data base: this is required to receive discharge summaries and admission / discharge notification messages about ‘Winter Strategy’ patients.

Some ideas to get your patients on board (April - May):ART PCMH family dark background

  • Contact patients and invite them to be involved.
  • Inform patients about what to expect.
  • Gather and document patient / participant consent if relevant.
  • Add patients to ‘winter strategy register’ to track and monitor progress.
  • Collect patient experience measures at the earliest point of contact - COORDINARE can assist with this.
  • Collect clinician experience measures at the earliest point of contact - COORDINARE can assist with this.
  • For relevant patient cohorts, commence care planning. Does the person have an up to date GPMP, if relevant? What does the individualised care plan look like for each patient this winter? See Phase 3 for approaches to including care planning this winter.

Individualised care for the winter flu season draws on the following (May - September):

Person centred care

Comprehensive care

  • Care plans and exacerbation / action plans are developed with patients and they receive a copy of the plan. Plans are reviewed regularly to ensure patients understand them and are still relevant. Patients and carers receive ongoing coaching and support to exercise self-management and use their exacerbation / action plan when needed.
  • Where relevant, patients are referred to the Chronic Disease Management Team or similar e.g. ’Connecting Care’ or Integrated Team Care (ITC) from the Local Health District to assist in education and self-management coaching.
  • Patients’ broader health and well being needs are considered, and they are referred to social support or other clinical services as required. This can be done by accessing HealthPathways Illawarra Shoalhaven or ACT & Southern NSW.

Access to Care

  • Patients know who their main primary care clinician is and how to contact them.
  • Plan how patients can access support when needed, especially as indicated in their care and action plans.
  • Plan how the practice will manage any potential surge in flu vaccinations, consider inviting patients to a planned clinic / vaccination day.

Coordinated CareART PCMH20coordinated20care

  • Ensure the patients’ My Health Record health summaries are current and uploaded, include a care plan and where necessary patient action plans. A care plan is for all patients who have others involved in their care and/or have ongoing health issues, to ensure everyone is on the same page as to what matters to the patient (goals, values and preferences). An action plan (also known as acute plans) are part of the patients care plan providing written information reminding the patient what to do when things go wrong, or symptoms occur.
  • Communication with other services supporting patients (e.g. allied health professionals, aged care services) is effective so that the care is coordinated and properly documented.
  • Ambulance care plans are in place to avoid ED presentation.
  • Consider whether the patient would benefit from a Home Medication Review (MBS item 900) with a pharmacist.
  • Where relevant, referral to Connecting Care Program in Illawarra Shoalhaven for patients requiring home visits / follow up.
  • There may be opportunity for practices to work in collaboration with local LHDs. Please discuss this option with your HCC.

Quality Improvement and Safety

  • Ensure that shared health summaries are accurate, current and include medication lists.
  • Plan your model of service delivery - this could be via simple recall and reminder systems, in conjunction with flu vaccination and/or GPMP/TCA review, as they come in for appointments. You may choose to run a clinic or you might have another method. COORDINARE can support you with identifying and developing the most suitable model for your practice.
  • Collect patient experience measures - COORDINARE can assist with this.
  • It is important to track your patient progress - COORDINARE has resources to support you with this.
  • Practices can apply for a one off payment for participating in the winter strategy to cover quality improvement activities including; data cleansing around specific indicators, planning meetings and initial set up of processes, evaluation / report writing, time to undertake regular practice meetings and meetings with COORDINARE, as well as access a variety of education / training opportunities.

Program evaluation and learning / sharing

  • Participate in a monthly check in with your HCC to see how things are going and if any support is needed. This could be done face-to-face, or even by phone / email if things get busy.

Lessons for 2019 (October):ART 20PCMH20tick

  • If you ran a specific program and/or clinic with patients, let them know it is now finished for 2019.
  • Ensure all patients and clinicians have completed their experience measure questions.
  • Collate outcome measures.
  • Complete and submit your final report - COORDINARE will provide you with a short template to help you do this.