WS18 PLANNING GUIDE
Joining the Winter Strategy requires some degree of planning. The WS18 Planning Guide has been developed to assist you to systematically work through and clarify who will be responsible for the different activities in WS18 and how they will have the time required to do the work.
In order to complete enrolment you are required to:
- Download and complete the WS18 Planning Guide by making brief notes in the column provided, and
- Save your completed guide electronically and upload it when asked on the enrolment form.
The WS18 Planning Guide is not intended to overly prescriptive or bureaucratic and your notes do not need to be too detailed. The Guide is there to assist and support you to think through and plan ahead for Winter.
The guide is easy to follow and works through the four program phases as set out in the Program Overview and Calendar.
For more information or assistance please email or contact Bernadette Carter on 6618 5400
RESOURCE GUIDE TO ASSIST PLANNING
PHASE / PAYMENT @ $37 per hour / PROTECTED TIMEPRACTICE PREPARATION & ENROLMENT
4 WEEKS
05 MARCH TO 29 MARCH / Practice payment $370 (one off) / 10 hours
PATIENT REGISTRATION AND CARE PLANNING
8 WEEKS
03 APRIL TO 25 MAY / $64.75 per patient (one off) / 1.75 hours per patient / Income per patient
64.75 (Registration)
+
198.40 (16 Weeks)
=
263.15 (Total)
For each patient in the program for 16 weeks
SERVICE DELIVERY
16 WEEKS
28 MAY TO 13 SEPTEMBER / $12.40 per week per patient for 16 weeks / 20 minutes per week per patient*
* Example - For 10 patients put aside 3 hours 20 mins of PN time per week (approx half a day per week)
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WS18 PLANNING GUIDE
TASK / WHATS INVOLVED / NOTES – WHO, WHEN? / DEADLINEPRACTICE PREPARATION AND ENROLMENT PHASE / Decide if the practice wants to join the program / This needs commitment from the practice owner(s) and staff. In particular the Practice Principal needs to have considered protected time for staff to do the winter strategyand that they are satisfied with the arrangements for patient consent and privacy and confidentiality. / Practice owner(s) are aware of what is involved and have decided to participate
Please check the box for yes. / 29/03/2018
Build your Team Work out who will be responsible for the different activities and time required to do the work. / Who will be responsible for different parts of the WS18?
How will protected time be arranged?
How will the team meet and communicate in-house?
How will WS18 developments be communicated throughout the practice team? / 29/03/2018
Plan how you will give priority access to your cohort / What will your system be? Are there existing arrangements you can use? How will everyone know what to do? How can you reinforce the system over the life of the strategy? / 29/03/2018
Plan how to contact patients / Plan how the patients will be contacted. Would you like to do it in conjunction with flu vaccination, for example, or as they come in for Drs appointments or other method?Who will do this? When? / 29/03/2018
Select your winter cohort / Clinicians can choose the winter cohort based on their knowledge of who they think is most at risk of hospitalisation and who would benefit most.
Plan how patients will be selected and the cohort list compiled and finalised.If you did WS17, consider the group you had last year – did they benefit? Were they the right group?
NNSW LHD will also provide a list of frequent hospital users from their database to each Practice for consideration. / 29/03/2018
Update your electronic messaging details / Ensure practice electronic messaging details are correct and up to date in the LHD database for the practice and all relevant clinicians. This is required to receive discharge summaries and admission/ discharge notification messages about Winter Strategy patients. A link to the update form can be found at Step 5 of the enrolment process and must be completed in order to finalise enrolment. Who will do this? / 29/03/2018
TASK / WHATS INVOLVED / NOTES – WHO, WHEN? / DEADLINE
PATIENT REGISTRATION AND CARE PLANNING PHASE / Invite patients to Register / Who will contact patients and invite them to register and when will they do this? / 25/05/2018
Provide patient with information / Who will Inform patients about what to expect, including the before and after surveys and how the surveys will be used? / 25/05/2018
Gather and document consent / See consent on the NPCHN website for instructions. / 25/05/2018
Allocate a Winter 18 Patient ID / NCPHN will give you a set of 100 patient codes to allocate, eg Practice A will receive WS180001 to WS180100, Practice B will receive WS180101 to WS180199 and so on.
You need to allocate a separate code to each patient. Find a system for clearly recording which patient has which code so that one code is not allocated to two people by mistake. / From 03/04/2018
to 25/05/2018
Register & Flag each Patient / Who will register each patient using a WS18 identification code and web form? And flag each patient in practice records to enable data extraction (optional)? / 25/05/2018
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? Is there a need to improve GPMP/TCA process or quality? See ServiceDelivery notes below for approaches to include in winter planning. Who will lead care planning? / From 03/04/2018
to 25/05/2018
Collect patient surveys / Patients will be provided with a paper survey and envelope.
Collect patient surveys at the earliest point of contact possible and hold for collection by NCPHN staff. Where will they be kept? / 25/05/2018
Ensure clinician surveys are completed / Every clinician (both GP and Nurse) participating in WS18 must fill out an electronic survey.
A good strategy is to allocate one person to the task of sending reminders and ensuring that everyone has gone online and filled out their survey. Who could take the lead on this? / 25/05/2018
TASK / WHATS INVOLVED / NOTES – WHO, WHEN? / DEADLINE
SERVICE DELIVERY PHASE / Person Centred Care / How can you tailor the winter plan to each patient’s individual needs and involve patients in decisions about what the care looks like?
Who will make sure that care plans and Sick Day Action Plans (SDAPs) are in everyday language that make sense to that individual patient and carer? No technical language jargon or acronyms.
Do your winter care plans include goals that the patient has come up with? Are they written in the patient’s own words?
Who will make sure that patients and carers (if relevant) are given a copy of, or access to, their health summary?
Who will provide patients and carers with coaching and support to exercise self-management and use their SDAPs when needed? / From 28/05/2018 to 14/09/2018
Comprehensive Care / Who will regularly review Sick Day Action Plans to ensure patients understand them and the plans are still relevant?
How will you consider relevant referral to?
- Chronic Disease Management Team (from the Local Health District) to assist in education and self-management coaching.
- Social support services as required
- Other clinical services as required, ensuring patients receive the right care when they need it?
Access to care / How will patients know who their main primary care clinician is and how to contact them?
How will patients get same day support when needed, especially as indicated in Sick Day Action Plan? / From 28/05/2018 to 14/09/2018
TASK / WHATS INVOLVED / NOTES – WHO, WHEN? / DEADLINE
Coordinated Care / Do you know who the CDM Team member is for your Practice? Do you know all the services they can offer or connect your patient to?
Who will contact the CDM team and provide your preferred method of contact for CDM staff doing 48 hour post hospital discharge on winter strategy patients?
Who will coordinate Allied health and extra care coordination if needed?
Who will check that the patients’ My Health Record health summaries are accurate, current and include medication lists?
Who will communication with other services supporting patients to make sure that the care is coordinated and properly documented? / From 28/05/2018 to 14/09/2018
Quality Improvement and Safety / What PDSA cycles will your Practice use this Winter?
- GPMP (current in the last 3 months)
- Shared Health Summary accurate, includes medications and uploaded
- Vaccination status
- Number of Sick Day Action Plans
Program evaluation and learning/ sharing / Who will participate in the monthly reviews with their Quality Improvement Support Officer to explore the implementation methods chosen?
Who will attend a mid-way workshop to share successes and gain further information? What successes could you share about? / From 28/05/2018 to 14/09/2018
Finalise strategy with patients and Practice / Who will be responsible for finishing up with patients and letting them know the strategy has ended for 2018?
How will you ensure that all patients and clinicians have completed follow up survey?
Who will attend follow up workshops to debrief and gather improvement ideas for 2019? / 05/10/2018
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