GP Referrals into the
Stawell Health & Community Centre
(SH&CC)
A joint project:
• Grampians Community Health
• Stawell Regional Health
• Grampians Medicare Local
(formerly WestVic Division of General Practice)
• Stawell Medical Centre
• Patrick Street Family Practice
• Sloane Street Medical Practice
• Budja Budja Medical Clinic - Halls Gap
Area Map
Stawell Health & Community Centre
Opportunity knocks…
• Co-location
• GP comment
• Meeting called late 2010
What GP’s Wanted
• One point of referral
• Guaranteed delivery
• List of services available
• Confidence in service
• Auto populating referral form
• Feedback
What Service Providers Wanted
• Improved communication
• Increase in quantity and quality of GP referrals
• Easier system for clients
• Long term aim
 electronic capability
 Integrated and coordinated care
Work To Date…
• Capitalising on existing centralised intake.
• Intake had undergone review.
• GP referrals sent to a secure fax.
• Administration staff acknowledge, record and
disseminate G.P referrals sent to appropriate
worker.
• Organisational policy/procedure on service
response is activated.
• Development of agreed processes.
Grampians
Community Health
Intake Flow Chart
Referral Template
• Use template GPs are familiar with
• Expand to include all services
• Medicare Local embedded tool in practice software
• Auto populate
G.P Feedback
• Generic feedback tool GPs are familiar with
• Based on State-wide Service Coordination guidelines for
G.P feedback
SH&CC Flow Chart for G.P Referral Feedback
First Review of Referral System
Modifications made at the first review
Referral acknowledgements
• Practice found the referral acknowledgements an
annoyance and were discontinued.
• The practice relies on the fax machine report alerting them
to an unsuccessful transmission.
• Has implications with MBS items – being reviewed.
Dissemination of referrals
• Simplified to a pigeon hole for each organisation
First Review
Modification to G.P feedback
• Responding to GP needs
• Limited to change in condition, DNA and outcome at exit of
service
Alterations to referral tool and information
• Change language of service descriptions
• More information required
• G.P requested more information on services provided
• Desk top brochure developed
Agreed to meet and review 6 monthly
Referrals from
June 2012 to July 2013
Total Number of GP Referrals
June 2012 to August 2013
Service Breakdown
Grampians Community Health
June 2012 to August 2013
Service Breakdown
Stawell Regional Health
June 2012 to August 2013
EIiCD Focus
The Ararat and Northern Grampians Early Intervention In
Chronic Disease (EliCD) Steering Committee is a
voluntary alliance of agencies working across Ararat Rural City
and Northern Grampians Shire to ensure a collaborative
approach to the utilisation of specific funding provided by the
Department of Health (DoH) for Early Intervention in Chronic
Disease.
Stawell
Regional
Health
East Grampians
Health Service
Podiatry
Grampians
Community
Health
Grampians
Medicare
Local
Lifestyle
Coordinator
Dietetics
Exercise Physio
Diabetes
Education
Grampians
Pyrenees PCP
East Wimmera
Health Service
Grampians
Region Dept
Health
Lifestyle Coordinator
The Steering Committee developed the concept of the
Lifestyle Coordinator to increase the sustainability of
behaviour change and act as a conduit between the
traditional ‘medical model’ and a community development
empowerment approach to change, aiming to assist the client
to better manage the lifestyle factors contributing to chronic
disease.
Using principles from Motivational Interviewing theory, the
Lifestyle Coordinator role explores client ambivalence and
attitudes to change and seeks to embed positive behaviours.
The role is performed by a ‘non medical’ practitioner who
works one-on-one in a supportive, flexible way to respond to
clients’ individual needs and circumstances, an approach
which reflects key characteristics of The Flinders Model of
Chronic Condition Self-Management.
Lifestyle Co-ordinator
The Lifestyle Co-ordinator aims to create links that promote
better whole health outcomes for people newly diagnosed with
a chronic disease by facilitating access and participation in
appropriate physical activity and social engagement
opportunities.
The coordinator is expected to create or
connect a network of opportunities to allow clients the
opportunity to choose from available program.
• Almost 100 clients with a chronic disease diagnosis have
Been referred by local GPs to this program since June 2012
Evaluation Opportunity
• WestVic Division (now Grampians Medicare Local)
• 30 random files from each agency audited
• GP referrals
• GP feedback
Stawell GP & Primary Health Service
Systematic Communication
2012 Review
Evaluation of G.P Referrals
• Elements omitted due to the information not being
requested as an auto populated field
• Challenge is to keep it simple and time effective for GP’s
while meeting accreditation standards
• Inclusion to be reviewed at next meeting
Evaluation of G.P Feedback
• Medicare number most commonly omitted field – has since
been included.
Conclusion
Since the introduction of a coordinated systematic referral
and intake process in 2011 by Grampians Community Health
(GCH), Stawell Regional Health (SRH) and Stawell Medical
Centre (SMC) the following changes have been measured:
• increase in documented GP referrals
• increase in referral quality
• increase in GP feedback provided
• increase in GP feedback quality
Stawell GP & Primary Health Service Systematic Communication Report – November
2012 Review. Joanne Martin Grampians Medicare Local
Conclusion
The system and tools have been reviewed with a review
scheduled biannually. Changes have been implemented with
consensus from all parties. The system has now expanded to
include all four medical centres:
• Stawell Medical Centre
• Patrick Street Family Practice
• Sloane Street Medical Practice
• Budja Budja Medical Centre
and includes referrals to the Northern Grampians Shire HACC
Services.
.
Positives…..the planets aligned
•
•
•
•
•
•
Opportunity presented
Willingness to work to common goal
Agencies history in partnership work
Co-location
GCH Intake process review
Staff acceptance of change
Difficulties Encountered
• Accessing GPs or Practice Managers to discuss services and
process
• GP understanding of client consent and implications
• Not enough information from GPs to process referrals
• Communication and knowledge of changes in services
Where To From Here?
• Moving toward electronic transmission
• Conversion of fax transmission to email
• Interfacing Connecting Care and Argus
• Grampians Community Health services delivered
in Ararat and Horsham areas
• Undertake work to include Wimmera Uniting Care
(child and family services)
• Further refine the process
Contacts
Katrina Toomey
Kate Astbury
Health Promotion Coordinator
Stawell Regional Health
Sloane Street, Stawell 3380
Ph 5358 8611
Extended Care Manager
Grampians Community Health
60 High St Ararat
Ph 5352 6200
katrina.toomey@srh.org.au
www.srh.org.au
kate.a@grampianscommunityhealth.org.au
www.grampianscommunityhealth.org