1) Medicare Locals

Also known as Primary Health Care Organisations (PHCOs), with responsibility for health planning and coordination of primary care services. Medicare Locals will be independent companies with local boards, rather than an arm of government.

Over time, it is likely that Medicare locals will replace Divisions of General Practice including ours, however there is considerable negotiation yet to happen between the State and Federal governments about what this actually means.  Our major concern would be that the support and services currently provided to practices will continue beyond this transition. BDDGP would expect to transform into a Medicare Local if offered the opportunity. This might include the redrawing of geographical boundaries and combining with Westvic Division to create a Grampians regional organization.

A national After Hours phone service will facilitated through Medicare locals, which will source local GP services when required. New funding arrangements will be developed for after-hours primary care services by 2013/14.

2) Personally controlled electronic health records

BDDGP will aim to position the region to best support the implementation of electronic patient summaries, unique identifiers for patients and electronic health records. Our local work with Argus places us well ahead of many other divisions in this regard.

3) General practice infrastructre

Funding will be made available for up to 425 existing General Practices across Australia to apply for infrastructure grants. Recently 3 local practices responded to a funding opportunity in January to expand – all with a view to increase the teaching capacity for medical students. As a result of this announcement, it is hoped that these requests will be funded.

Funding for 23 more GP super clinics nationwide.

4) Practice nurse incentives

$25k per full time equivalent GP for a registered nurse (or $12.5k for an enrolled nurse). Maximum payment per practice is $125k per annum. Only accredited practices may apply.

With $390m allocated over 3 years, we need to clarify what is regarded as new money, especially for rural practices.

5) Training more doctors

This policy was announced previously. Will increase GP registrar and pre-vocational general practice training opportunities for the region over time.

6) Coordinated diabetes care

Refers to a capped/flexible funding for treating patients with type 2 diabetes. Incorporates GP and allied health time for each “enrolled” diabetic with one general practice.

Commences July 2012, details on how this will work to be announced.

7) Preventative health

Funding aimed at prevention rather than cure. Waiting for details on this one.

8) Mental health – ATAPS extension

We currently fund counselling at Pomegranate House for GP-referred patients.

This budget announcement extends on our current program brief that incorporates care packages for those with severe mental health illness.

9) Mental health nurse initiative

Mental health nurses have been placed in 3 local general practices on a sessional basis.  The budget confirms the ongoing funding of this program.

1. We need more time … to be able to find things quickly (resources, websites, templates etc.)

Julian Laffey has been developing “GP Launchpad”, a new interactive feature to be announced soon. It allows GPs, PNs and PMs to have quick customised access to web resources while consulting, activated by a keyboard shortcut. Favourites under this system may be customised by individual users. [Work in progress, stay tuned -Julian]

2. Insufficient staffing impacts on new initiatives and is dependent on the availability of skilled practice staff

We are providing a practice nurse locum service. It’s currently available 3 days/week with a large range of services on offer, including immunisation, CMAs, GP Management Plans, Diabetes Reviews and Diabetes Nurse Educator services.  For all enquiries please contact Michelle MacGillivray or Gail Schuler at BDDGP.

3. The referral pathways for diabetes prevention programs are not clear

The referral pathways have been simplified and can be found on our diabetes prevention page.  Even though changes to the MBS items in May will alter your billing processes, the referral pathways will remain the same and this table can still be used as a reference.

4. All practice staff want to know who and what is out there (allied health providers, information, other supports)

There is an updated information table on diabetes prevention providers on the website, which indicates when the next prevention groups are commencing and contact details for providers. BDDGP is also planning to develop an allied health register, similar to the specialists service directory, but this will take some time before completion.

5. You would like some help in identifying patients at risk of developing diabetes

Practices can be paid to identify and refer eligible patients aged 50 and over to a diabetes prevention (Life!) program.

Diabetes Australia Victoria will pay $280 + GST for 8 hours work with evidence of at least 5 referrals to a Life! Program, and the second invoice of $280 + GST will be paid after evidence of at least an additional 10 referrals to a Life! program. Contact me at heatherc@bddgp.org.au for more information and/or a practice visit.

Have you signed up for the Pen CAT tool? Tanya Gradolf is available to speak to and demonstrate the effectiveness of this tool in managing information about your patients.

6. Please BDDGP – tailor information and visits to suit the practice requirements

The Practice Development Team at BDDGP is currently working on an additional liaison support to practices, to better assist you in a resource capacity. The details have not been fully completed but they should be in soon and all information will be provided at that time.

7. There was some ambivalence about education on new programs and government stuff and only 25% of practice nurses surveyed believed formal education sessions were the best approach.

In response to some suggestions in the diabetes prevention survey, Jo Millard has organized a social evening for practice nurses to meet their colleagues in a supportive and relaxing environment.

This will be an informal get together at Oscar’s Café Bar on May 4th at 6pm for drinks and nibbles. No formal speakers or nothing!  RSVP to jom@bddgp.org.au or phone 5331 6303.

The change

• Goal: systematic approach to the handling of urgent faxed results after hours
• How we know it’s an improvement: survey doctors and clerical staff
• Idea: meet with doctors to ask for input

PDSA cycle

Plan

• What: doctors’ meeting
• Who: manager and all GPs
• When: 21/5/09 at 12.30pm
• Where: boardroom
• Predictions: not all GPs can attend
• Data to be collected: list of ideas on how to improve system

Do

Meeting held, those GPs who did not work on a Thursday could not attend, and apologies received from two other doctors.

Study

All GPs who attended meeting actively participated with view on how best to handle late night urgent results.

Decision made to test a 7.00 pm urgent result appointment with a doctor working in the evening on a rotational basis so that all GPs were able to assist with the urgent result appointment. This would enable GPs to have time to review patient file.

GPs wanted clerical staff advised of this appointment and also of the need to only use this service if the GP who ordered test was not working.

Also GPs requested that confirmation be made that pathology and radiology company used had after hours contacts.

Act

Meet with clerical staff and advise of test changes, contact pathology and radiology companies to ensure they have afterhours contacts, survey to be sent to doctors and clerical staff.

NEW cycle

Plan

• What: advising staff of new faxed urgent result system test
• Who: TC
• When: via email and then on agenda for staff meeting
• Where: clinic
• Predictions: some people may need clarification of new protocol
• Data to be collected: input from clerical staff

Do

Email sent outlining new procedure for faxed urgent results of an evening to both clerical staff and all doctors. Clerical staff advised of the new rotated result appointment for one GP at 7.00 pm. Also remind that first option should always be GP who ordered test if they were working.

Study

Clerical staff were very keen to participate in a more systematic approach to urgent faxed results.

Act

Surveys to be sent out to all staff in 2 weeks’ time asking how the new protocol was going.

Well?

Could your practice implement this methodology? Want to learn more on implementing PDSAs? Contact me or Tanya Gradolf at the division.

Nicole McGrath and Dr Michael Pickavance (Mair St)

Dr Jim Thomson and Marg Wilson (Sturt Medical)

Helen Payne, Gail Buchanan, Belinda Hunt, Karen Park, Dr Ruth Hand and Lisa Lulham (Carn Brae)

Change can take time. Be patient.

Hugh Kearns and Maria Gardiner have spent 10 years working with doctors to improve their psychological well-being and sustainability. They have also acted as consultants for a number of medical organisations including the APCC.

They tell us that most GPs love their jobs – if only there wasn’t so much of it!

They have recently written ‘The Ultimate Time Management Guide for GPs’, which collates the results of their research and their experience working with thousands of doctors.

The book makes the bold guarantee that if you invest the one hour it takes to read it, and try out just one of the strategies, you’ll get a minimum extra two or three hours back a week in return!

The alternative, as we know well, is that if you keep doing what you’re doing, you’ll keep getting what you get.

Right from the start the book is refreshingly practical, and is full of shared real-world stories. Clearly, Hugh and Maria understand the life (and thinking) of GPs;

One registrar told us that us that she regularly ran late. It got to the point where she wouldn’t drink water during the day so that she wouldn’t have to go to the toilet. Because this would have meant walking out past the waiting patients who she thought would be very displeased to see her taking a break while they were waiting.

As well as lots of very practical advice (“Do paperwork with the patient present”. “Book your annual leave now – and tell your family”), the book busts many of the myths that GPs believe.

Hugh and Maria tell us that “it’s the thought that counts” -  their background  in Cognitive Behavioural Therapy is apparent. The book challenges us to replace our usual ways of thinking with a more accurate appraisal of reality. “I think that the community will suffer if I say no. But the truth is I can’t be responsible for everyone and everything – I have a limit.”

Mythbusting

• I’m indispensable
• I can do it all
• I don’t need a break
• It will get better
• I don’t have time

The Guide is broken down into small bite-sized sections to allow the time-poor to read little bits when time allows. My personal motto is ”always put off till tomorrow anything that I could do to today“, so I was glad to read the chapter on procrastination. (And, I’m writing this article, so it worked!)

Do you find it hard to say no? Try ‘the spouse test’ (“we sometimes tell doctors that they shouldn’t make decisions unless they have a consenting adult present”).

Other subjects discussed include setting priorities (where does your family fit? yourself?), running late, beating the paperwork monster, dealing with email, training patients and managing staff. Sustainability is a key issue (“Its a Mararthon, not a Sprint”).

There is a special section for rural docs.

Hugh and Maria – your ‘minimum extra two or three hours a week back’ guarantee is safe. I would highly recommend ‘The Ultimate Time Management Guide’ to all GPs (and their spouses!). I am sure that all of us can benefit from some of the practical suggestions and improved ways of thinking outline in the book.

The Ultime Time Management Guide for GPs is available from ithinkwell.com.au. The APCC has purchased a number of copies that we will give to a selection of practices who post their top Time Management tip to collaborators-talk@lists.apcc.org.au or as a comment here.

Please note that Michelle MacGillivray has a copy of this book which may be loaned out, contact her at michellem@bddgp.org.au.

“The future depends on what we do in the present” -Mahatmar Ghandi

As you know, Carn-Brae Clinic has been involved in the APCC Collaborative program. Many BDDGP practices felt that they could not participate in the State wave of the program when it was offered in 2008, due to the time involved to attend the 3 learning workshops in Melbourne.

Here is another opportunity for you. How about a VIRTUAL WAVE? There is a lower time commitment for practices to participate, as the program will be accessible online.

Your staff will not have to travel and you will be supported by division staff as you participate in the program. In addition, your practice will be paid an incentive to participate.

What kind of benefits could your practice experience? To give you an example, Carn-Brae Clinic has experienced the following clinical improvements in a 7 month time frame:

1. Establishment and maintenance of an accurate Diabetes register.
2. Establishment and maintenance of an accurate Coronary Heart Disease Register (CHD).
3. Patients with CHD whose last recorded BP within the last 12 months <140/90 mm Hg – 30% improvement
4. Patients with Diabetes with a last recorded HbA1c of <=7% within the previous 12 months – 30% improvement
5. Patients with Diabetes with a last measured total cholesterol of <4mmol/l within the previous 12 months – 20% improvement
6. Patients with Diabetes with a last recorded BP reading of <=130/80 mm Hg within the previous 12 months – 20% improvement

Carn-Brae Clinic have something to celebrate! Congratulations to the team for their work and commitment to the program.

So what is required of your practice to participate?

1. a GP and a practice staff member to actively participate in the APCC virtual workshops
2. undertake work in the required topic areas (diabetes, secondary prevention of coronary heart disease, patient access and care redesign)
3. submit PDSA (Plan, Do, Study, Act) cycles each month.
4. submit data on a monthly basis

Your practice will be fully supported by BDDGP through this process.

Pick up the telephone and call me, as recruitment of practices is underway now. Recruitment will stop on July 31 2009.

If you would like to talk with Dr Frank Marton or Ms Gail Buchanan at Carn-Brae Clinic to learn more about their experience, call me on 5331 6303 to find out when they are available to speak with you.

GP Workforce

Local effects of replacing the RRMA with the ASGC-RA system from July 1^st, 2009:

• 10 year moratorium for International Medical Graduates decreases to 9 years for RA 2, 7 years for RA 3.
• Bonded Medical Places and Medical Rural Bonded Scholarships (undergraduate) have a similar time reduction for return of service obligations, to IMG moratorium times.
• HECS debts will be repaid over 5 years for RA 2, 4 years for RA 3.
• Under the new General Practice Rural Incentives Program, a relocation grant from the city is $15000 for RA 2, $ 30000 for RA 3.

Note: all Division practice locations are RA 2 (inner regional) except Lake Bolac, which is RA 3 (outer regional).

Retention grant payments on a sliding scale (formerly not accessible by Ballarat city GPs)  [source]

Time in Location (Years)

For comparison of the new retention grant payments with former rural incentives see http://www.agpn.com.au/client_images/272841.pdf

All Division practice locations will be eligible to seek locum support under the new National Rural Locum Program.

Practice Incentive Payments

There are currently no plans to change the area classification system used to calculate Practice Incentive Payments. These payments will continue to be based on RRMA classifications.

Nursing

Nurse practitioners and midwives to gain access to MBS and PBS.

Consolidation of programs:

• Bringing Nurses Back into the Workforce
• The Rural Nurse Initiative (Nurse Scholarship program)
• Additional Practice Nurses for Rural Australia
• The Mental Health Postgraduate Scholarships scheme

Jo Millard, our Nursing in General Practice Program Coordinator will contact you with further information as she receives it.

Chronic Disease Management

Cessation of funding for four Australian Better Health Initiative components from 30 June 2010:

• promotion of the 45 year old health check
• supporting lifestyle and risk modification
• encouraging self-management of chronic disease
• the primary care incentive fund

Closing the Gap

Significant resources for general practice and Divisions to close the gap including practice incentive payments, preventative measures, chronic disease management and self management initiatives, as well as improved service coordination through Division-auspiced outreach workers.

Immunisation

PIP for immunisation will be stopped for non-accredited practices unless they store vaccines appropriately.

Mental Health

The Mental Health Support for Drought-Affected Communities Program has been continued for another year.

Mary Shone, our Mental Health Program Coordinator, will contact you about other mental health changes as soon as she receives relevant information.

National Prescribing Service

Increased funding for National Prescribing Service educational programs, extension of the program to include education about radiology services.

Training

• Prevocational General Practice Placement Program places will increase by 160 places per year to achieve 410 annual placements in 2012-13 (a real increase)
• GPET to administer PGPPP (previously ACRRM and RACGP)
• Additional GP registrar training places; 75 this year, 100 next year
• Extended rural placement time for registrars from 6 to 12 months (more registrars for longer time in the district)
• Consolidation and Restructure of GP Regional Training Providers
• Increased funding for Rural Clinical Schools, expansion to nursing and dental training

Please contact me at the Division for further clarification of these changes.

I have been at the practice for almost 16 years, with the last five as manager. During that time I have seen many changes, with GPs and staff coming and going.

General Practice has changed and evolved over the years, especially recently with an emphasis placed on being proactive with regard to patient care in addition to all aspects of compliance.

All of this brings me to our participation in the Australian Primary Care Collaborative (APCC) program.

When first approached by the Ballarat Division, I thought “I really don’t know whether I can be bothered with all this, I have enough to do“.  And, to be honest, for a few weeks, I did find it a bit daunting, there was quite a bit of reading to do and then I needed to learn how to navigate around the APCC website, enter data each month and complete PDSA cycles (Plan, Do, Study, Act). The GPs were a little bemused about the whole thing and the prevailing attitude was; what’s in it for them?

As time went on and after attending 2 workshops in Melbourne, I found that I had much more of a grasp on the whole concept of what the Collaboratives was trying to help the practice to achieve.

We have only been involved since October last year and I feel that we have made pretty good progress.

For example, practice meetings; these were held fairly infrequently and were too informal.  We now have regular monthly meetings with a written agenda, one of the staff takes minutes and all staff attend. We have found these meetings very valuable for open discussion regarding practice procedures and new initiatives.

Being involved in the Collaboratives really forced us to clean up our clinical data on our computer systems. In October last year the practice population as calculated by the PEN Clinical Audit Tool was over 26,000. This did have to be addressed because all our calculations regarding different groups within the practice would be totally inaccurate.  We have used a number of strategies to address this including inactivating non-active and deceased patients (those of you with MD3 would be able to do this much more quickly than our manual work needed with MD2).  We had some patients still on the system who were 120 and even 150 years old!

After diligent and ongoing work, mostly done by our reception team going through patient lists and inactivating patients one by one, our practice population now stands at just over 6,000.  We are very happy with this outcome.

PDSA (plan do study act) – this concept was a little difficult to understand at first and initially, the process of entering data and writing up the PDSAs on the APCC website was a bit bewildering.  This is where the division’s ongoing help and support was invaluable.

Through the workshops that Dr Frank Marton and I attended, we gained an understanding of the whole process.  The workshops, I should point out, were very well organised and the speakers were informative and entertaining.

I am now becoming used to having a head full of “PDSA possibilities”. It affects you like that!! And it’s amazing how the process just rolls along.  I need to keep in mind that the Collaboratives Program is made up of small steps, which, when you look back, have made quite a substantial difference to the practice already.

We now have up-to-date diabetes and CHD registers.  Helen, our practice nurse has been involved in some of the PDSAs regarding consistent coding for diabetes (eg Type 1 and Type 2) and for CHD. Data has been corrected to be consistent across the practice and the GPs are cooperating by using uniform coding when entering their data.

We have improved quality of care for people with diabetes by conducting searches using Medical Director and the PEN Clinical Audit Tool to ascertain which patients need review appointments, HBA1c blood tests etc.

We have also enlisted the services of Lachlan Campbell, Diabetes Nurse Educator, for weekly clinics.  This has worked very well.

We have conducted patient surveys and have run capacity and demand studies.  We are reviewing these at present to see if our appointment system can be improved.  As you all know, this area can cause a lot of stress, both for reception staff and GPs.  The Collaboratives Program does supply many strategies for improvement in this area of access.

When you are participating in this type of program, it is always beneficial to get an idea as to how you are going with it all. The APCC sends feedback graphs every month and we can benchmark ourselves against other practices in Victoria and Tasmania.  This feedback has shown that we have made excellent progress.

Contact Michelle MacGillivray (michellem@bddgp.org.au) for more on collaboratives, or Tanya Gradolf (tanyag@bddgp.org.au) about the PEN clinical audit tool.

Currently four coaching service providers are available for coaching sessions, including the company involved in the Sustainability Seminar.

General practice owners or managers interested in succession planning are encouraged to apply for this One on One coaching, for financial, accounting, recruitment or other forms of advice and assistance.

For more information, please contact Sue Torwick at RWAV on 9349 7800.

RWAV’s Business Advisory Services Guide, including profiles of the approved coaching service providers, is available here.

For application forms for the One on One business coaching sessions, please contact Angela Aldred at the Division on 5331 6303.

Criterion 1.1. of the RACGP Standards For General Practice 3^rd Edition, which is dedicated to the delivery of Home and Other Visits, states:

“Regular patients of our practice are able to obtain visits from a GP (where such visits are safe and reasonable) in their home, residential aged care facility, residential care facility or hospital, both within and outside normal operating hours.”

But what about the community services who access patients for assessment and care provision?  Ballarat and District Nursing and Healthcare, for example, provides 24 hour care services to:

• rural and urban areas
• Supported Residential Service (SRS)
• private houses
• workplaces

General Practice can assist these community services in hazard identification by any including information known about the patient’s home environment, such as:

• patient’s contact details
• another contact person and details (very helpful if patient has cognitive deficits, is deaf, or physically disabled)
• any known aggressors or people who may exhibit violent behavior
• dogs

When community services first visit a patient at home, they often use tools such as the Home Hazard Checklist (currently under review) to identify any hazards and alert other staff visiting. However, early identification and more detailed information on GP referral can make their work safer, easier and more efficient.

From left: David Dahm (Health and Life), Soni Stecker (Ballarat Mind Body Medicine), Michelle MacGillivray (BDDGP), Talei Deacon (UFS Medical), Trish Turner (Creswick Medical), Wendy Grayland (Ballan and District Health Services), Meredith Johnson (Springs Medical), Anne White (Mair Street), Anne Appledore (Ballarat Group Practice)

The all day workshop was well received, as evidenced by the testimonials below:

“Personally the seminar was worthwhile, not previously having had as much knowledge of the various business models of general practice. I now understand how our business operates the way it does, why we do things in a particular way and not in another way, e.g. trust structures.”

Dr Richard Patterson, Creswick Medical Centre

“I thought the workshop was excellent, David Dahm was very easy to listen to and I picked up quite a few pointers that I will be following up on. The session has made me think about how we are utilizing our nursing staff. I wished one of our GP principals was there as I know they would have benefited from the session.”

Ms Anne White, Mair Street General Practice

“What he said is really relevant and thought provoking. This is the second time I have heard him speak. I have already been onto our practice solicitors this morning about relevant information received at the seminar.”

Ms Meredith Johnson, Springs Medical Centre, Daylesford

The seminar was sponsored by the three Divisions of General Practice and the Rural Workforce Agency of Victoria (RWAV). RWAV is providing practices with Business coaching to the value of $1500 as part of their Sustainable Practice project.