PART C
3.1
PRIORITY STRATEGIES
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PCP-South West review of governance, role and function
Healthy Communities Strategy
Vascular Disease Strategy
Service Co-ordination
Access to Information About Services
Footholds on Safety
Domestic Violence
Oral Health
OPTION 1 Older people
OPTION 2 Fluoride
OPTION 3 Pre schools
Integrated Health Promotion
Depression and social isolation in people with cardiovascular disease or other chronic
illness
Eat Well Be Active
These operational plan strategies are described in accordance with the prescribed template (Appendix
1) with the Integrated Health Promotion Plan written to comply with the template and the prescribed
Integrated Health Promotion Program Summary Grid (Appendix 2)
Priority for Action:
PCP-South West review of governance, role and function.
The PCP-South West Management Team acknowledges that the statewide primary care
partnership and local primary care enhancement.
The overall objective of the consultancy will be to determine the future directions for the PCPSouth West for the period 2003 –2005. As a part of this review, stakeholders will determine
whether the PCP-South West be disbanded or continue. To continue, consultation with
stakeholders will be required to determine the vision, mission for the partnership, review strategic
direction and to decide on governance arrangements and options that will enhance and enable its
role and function.
Rationale/Evidence:
In August 2003, the Victorian Department of Human Services (DHS) will be releasing a
“Discussion Paper” outlining the options for the future role and function of the 32 PCP’s across
the State. At a local level and at the same time, two critical reports will be released.
The first, will provide an overarching sub-regional strategic plan for health services providers in
Warrnambool City, Moyne Shire and Corangamite Shire. This plan will scope current and future
community needs; assess current service provider linkages and partnerships; investigate
improvements in service co-ordination and identify service gaps and areas of service duplication.
It is envisaged that this plan for the area will be developed for the period July 2003- June 2008.
The second report due for release in July 2003 will also influence the future role and function of
the PCP-South West. This project undertaken by the Barwon South West Office of the DHS will
develop a model of service provision and delivery that will enhance access to allied health services
in the Warrnambool catchment area. The model will also enhance outreach services
provided to smaller agencies across the PCP-SW catchment area.
Problem Definition:
Target Group: PCP-South West stakeholders
Goal:
To clarify the purpose of PCP- South West in the development of a functionally
integrated primary care service to improve the health and well being of the
residents of Corangamite and Moyne Shires and Warrnambool City.
Objective:
To define the role, function and governance for the PCP-South West.
Solution Generation:
Key Deliverables:
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Vision & mission statement for the PCP-South West 2003 –2005
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Role and function of the PCP-South West 2003 –2005
Model of governance for the PCP-South West 2003 –2005
Implementation work plan to achieve the preferred model of governance
*The model will include components such as: objectives, processes and arrangements for
accountability, key performance indicators and stakeholder consultation. Capability to meet
objectives will also require definition including leadership, financial and human resources
management. Staff and Management Team composition and attributes such as specific
knowledge, competence, skills and expertise will also require definition.
Evaluation:
Reach:
Impact:
Number of stakeholders participating and contributing to the review
Development of performance indicators to monitor the role and function of the
PCP-South West including governance.
Integration with Service Co-ordination:
Service Co-ordination is an integral component of the PCP strategy and will be included in role
and function of PCP – South West and key performance indicators.
Support & Resources:
Stakeholder involvement including PCP-Member participation
Central to the consultancy methodology will be in-depth and confidential consultation with key
stakeholders. Upon completion of the consultation, options for the role, function and governance
arrangements for the PCP-South West 2003 –2005 will be determined by majority vote of the
membership.
The appointed consultants will be required to work with stakeholders and facilitate decision
making of the membership and to develop a 6-month implementation work plan including time
frame, responsibilities and implementation indicators. Thereafter the consultants will be required
to be available as requested to mentor the partnership in order to implement the work plan for a
period of 9 months on an agreed fee for service basis
Budget
See Budget section 4
Time lines
The Project Brief will outline timelines for the consultancy.
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Priority for Action:
Healthy Communities Strategy Proposal
Increasing access to dental health services
Rationale/Evidence:
The purpose of the Healthy Communities Project is to ensure an integrated response to
implementation of planning priorities between regional stakeholders in South West Victoria.
The Healthy Communities report (2001) that guides the project identified a number of themes
through its consultation with agencies, consumers and community members, including the regional
Aboriginal community. Issues identified in National Health Priorities and in Victorian data, including
Burden of Disease evidence, were then determined to be a local or regional health priority under
municipal health, community safety and/or Primary Care Partnership planning models.
One aspect of the Healthy Communities consultation process identified a critical need to improve
rural communities access to public dental health services across the region. This was
recommended as a priority in the report, under both the Municipal Public Health Plans for the five
municipalities and the region’s two PCPs Integrated Services Plans.
Problem Definition:
For the purposes of definition for this component of the PCP – South West Community Health Plan
2003 –2003, the target group for this priority is the community serviced by the PCP – South West
who requires public dental health care.
An indicator that highlights the lack of public dental health services is the two to three year waiting
lists across the region for non-urgent cases, with an estimated 300 waiting in Warrnambool alone.
This equates to a lack of service providers, ie, dentists for the general community and particularly
for the region’s Aboriginal community. Added pressure will occur in mid-June 2003 when another
public dentist will cease service delivery in Hamilton.
Linkages:
The Primary Care Partnership South West (PCP SW) have prioritised the problems associated with
the public dental health system in their Community Health Plan as a response to the Healthy
Communities recommendations. The Partnership recommends a strategy aimed at developing an
integrated planning response to overcome barriers to the availability of, and access to, public dental
health services. This includes the recruitment and retention of qualified dentists to the region
because the issue does not necessarily arise from a lack of funding.
A key measurement of this strategy is to develop staged action plans so progress demonstrates
improved access to public dental health services.
Objectives include Convening a regional working group to develop public health initiatives by aligning defined
regional commitments in the Healthy Communities Report with strategy objectives of the
 PCP-South West Community Health Plan 2003-2004, an example being public dental health
services
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Promotion of integrated health planning by nominating PCP representatives to the Healthy
Communities Steering Committee and associated Working Groups
Promoting in-common health promotion strategies, an example being to continue promotion of
the current oral health program
Seeking and distributing funding for the recruitment, professional development and retention of
needed health professionals to the region, an example being qualified dentists
Developing and supporting action plans to facilitate better access to service, initially focusing
on public dental health services
Liaison and reporting on the implementation of regional issues to the PCP-South West
Management Team, an example being the dental health services priority
Interrelated Strategies - ‘Supporting Relocation to the South West’ migration initiative:
In 2002, a needs-identification by Warrnambool City Council and the Greater Green Triangle Area
Consultative Committee (GGTACC) discovered the region’s key industries are suffering from a
shortage of both skilled and unskilled labour. The GGTACC had held a summit and recommended
the development of a strategy for programs to attract migrant groups to the region. The aim was to
develop population demographics that can boost the labour force, ie, younger men and families.
This also coincided with a goal of Warrnambool City Council to attract migrants to the area. The
GGTACC assisted Council to secure funding for a new project, the ‘Supporting Relocation to the
South West’ migration initiative (SRSW).
The SRSW project reflects current global and national circumstances and is focussed on attracting
and supporting 10 families from communities of refugees; five families holding Temporary
Protection Visas (due to arrive and be settled from July ’03) and five holding Permanent
Residency.
SRSW objectives and associated outcomes include attracting the targeted number of 10 families, a
communication plan, evaluation criteria and the development of a ‘dummies’ guide. Critical
success indicators include recent association with detention, a skills base, family configuration,
ability to settle and community cohesiveness.
The SRSW project will be resourced by a Migrant Liaison Officer (.6 EFT) who is responsible for
supporting the families to obtain and maintain housing, employment, education for adults and
children, medical services, community services and social support. The Officer will be supported by
a coalition of agencies (schools, the local TAFE, hospitals, community service agencies,
employment agencies, the division of GPs, etc.) led by the Warrnambool City Council.
Interrelated Strategies - ‘Cross-Cultural Awareness in Warrnambool’:
Background research on the SRSW project revealed that Warrnambool has the facilities and
opportunities available to make a ‘relocation to the South West’ project succeed, but found that
further effort on cross-cultural awareness is required in critical sectors such as education,
employment, health, primary care and community services, employment and law enforcement.
Surveys conducted by the local newspaper found a majority of Warrnambool residents support the
concept of attracting culturally and linguistically diverse groups. However, the project is anxious
that the area’s traditional reluctance to accept change may arise.
Therefore, an action research project will operate concurrently with the SRSW and its Migrant
Liaison Officer. Titled, ‘Cross-Cultural Awareness in Warrnambool’’ (CCAW), the research will
provide for a structured evaluation of the community’s actual and potential capacity to welcome
and accept new migrant residents.
The project will also critically analyse the attitudes of organisations and key agencies in relation to
their ability and preparedness to provide services and equal opportunities to people of culturally
and linguistically diverse (CALD) backgrounds. It will therefore have a key role to play in informing,
advising and refining the ‘Supporting Relocation to the South West’ Project as it unfolds.
Its objectives will facilitate social change by –
 Examining, analysing and documenting attitudinal change towards people of culturally and
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linguistically diverse backgrounds in selected sectors of the Warrnambool community,
Assisting the community to reflect on strengths and deficiencies in its cultural awareness as a
welcoming and inclusive community to people of CALD backgrounds, and
To consider adopting recommended strategies to reinforce the strengths and to address any
identified deficiencies in the region’s ability to respond to the needs of the CALD community.
Solution Generation
The ‘Supporting Relocation to the South West’ migration initiative has proposed a partnership with
the South West PCP and the Healthy Communities Project. This initiative takes the form of a case
study proposal.
If implemented, the case study will facilitate success in the key performance indicators of the
GGTACC, SRSW and CCAW by highlighting positive achievements of the community’s ability to
support and include relocating migrants and strengthen the region’s cultural awareness.
Implementation of the case study will also facilitate the success of PCP-South West and Healthy
Communities Project key performance indicators by increasing the availability of, and access to,
public dental health services in the region.
Partnership Proposal:
The case study encompasses the issues of a refugee family that has made contact with the relocation
initiative and who wishes to relocate to Warrnambool. The family is being supported by the SRSW
initiative as the family meets the critical success indicators for the SRSW. These include recent
detention, a skills base, family configuration, ability to settle, and community cohesiveness.
The SRSW’s committee also includes other organisations that are crucial to the success of the
project and can therefore assist with planning and support of the case study proposal, ie,
Warrnambool City Council, South West Action Group for Refugees Inc., South West TAFE, South
West Local Learning and Employment Network and the Midfield Group of Companies.
The case study proposal put forward by the SRSW for adoption by the PCP-South West and
Healthy Communities is as follows Background:
 The family is Christian and consists of a husband and wife from Iran who have been in
detention for two years,
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The gentleman concerned is a dentist who qualified in India but had no access to practice for
the two years in detention and is not qualified to practice as a dentist in Australia.
The gentleman concerned trained at PMNM Dental College, Bagalkot, at Dharward University
in India. This means the gentleman concerned undertook his studies in English. His posteducation experience includes one year at a private clinic in India and eight months at a private
clinic in Iran.
The gentleman concerned sat for the required Australian exam in order to qualify to practice
here. He was marginally unsuccessful, ie, six points below the required pass rate. However,
this score was still significant given that he had no access to Australian textbooks or
observation placement during his time in detention.
Therefore, the gentleman concerned currently has approval to work as a dental assistant and
hygienist as his qualification is recognised by the Australian Dental Board.
Issues:
 The gentleman concerned is required to sit an exam in September 2003 in order to equate to
Australian qualifications, at a cost of $690.00.
 If successful in passing the exam, registration as an Australian qualified practicing dentist will
cost $4,000.00.
 In order to maximise success, the gentleman concerned requires the opportunity for
professional development and supervision in an Australian dental practice to observe and
become familiar with Australian standards. This can be achieved by volunteering at the public
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dental health clinic in Warrnambool.
Other Considerations:
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The resettlement funding via the SRSW has a limitation of two months support. Therefore, the
family requires an income, or additional financial support for an additional three months
minimum, until the exam results are processed and the gentleman concerned is recognised as a
qualified dentist in Australia.
Volunteering at the public dental health clinic in Warrnambool, with the expectation of
professional development and supervision, requires negotiation with South West Health Care,
who auspice the clinic.
Discussions with the Director of Medical Services, South West Healthcare, Peter O’Brien, and
the current Acting public dentist, Bill Robertson, of the Warrnambool public dental clinic have
resulted in approval to implement this model of professional support.
Proposal:
In summary, implementing the case study requires the PCP-South West and Healthy Communities
to work in partnership with the SRSW initiative to co-ordinate the professional development of, and
provide financial assistance, for the gentleman concerned to become a qualified dentist in Australia.
This will be in conjunction with a period of contractual agreement upon qualification for the
candidate to be employed in the public dental health clinic of South West Healthcare.
Integrated Strategic Outcomes:
The appointment of the gentleman concerned to a position of a public dentist will assist in providing
a positive outcome for the immediate and major service gap in public dental health services in
South West Victoria.
Other outcomes are described above in the ‘Solutions Generation’ section and overall will result in
the implementation and improvement of integrated regional health planning and cross-cultural
enhancement strategies. This, in turn, will assist in meeting key performance indicators for a
minimum of four regional programs.
Strategic long-term outcomes include contributing to a foundation for the on-going inclusiveness of
people from culturally and linguistically diverse backgrounds within South West Victoria, and
adding to its skilled labour force. This, in turn, will enhance the region’s reputation as a welcoming
and positive destination for migrants and potentially create a new support model for other rural
communities to attract and settle migrant or refugee groups.
Evaluation:
Reach:
The whole South West regional community will benefit by having its capacity to support people
from CALD backgrounds enhanced, including the benefit of attracting skilled labour, in the form of
a qualified dentist. As the dentist will be located in Warrnambool, the majority of patients would be
expected to come from the SW PCP’s catchment.
Impact:
The case study family will benefit from the resultant cross-cultural awareness raising and advocacy
that would be a component of their model of support. This would be directed at the sectors that will
impact upon their lives (employers, educators, estate agents and landlords, health professionals, law
enforcement and regulatory agencies, community service agencies, etc,).
Other key culturally diverse groups in the community (notably the Koori and same-sex attracted
communities) may ultimately benefit two-fold from this initiative, Firstly, from the ‘thaw’ of
Warrnambool’s conservative nature whilst and secondly, having the option of accessing another
public health dentist.
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Outcome:
Support, funding and advocacy by the Migrant Relocation Officer, co-ordination by Healthy
Communities, and professional development and sponsorship by the PCP-South West and South
West Healthcare will assist in the training and retention of a public dentist for South West Victoria.
Integration with Service Co-ordination:
If successful, the proposal will meet key measurements for three programs and South West
Healthcare, and highlight the positive aspects of integrated health planning. PCP-South West and
South West Healthcare in particular will meet their objective to improve access to public dental
health services. The Healthy Communities Project will ensure an integrated response to
implementation of regional health planning priorities and the SRSW Project will achieve it’s aim to
assist migrant refugees to successfully settle in South West Victoria.
Support and Resources:
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Through the identification of the above strategic issues and linkages, the Healthy Communities
Project seeks the following sponsorship from the PCP-South West
Provide the candidate with financial assistance for examination and registration fees,
Provide the candidate with financial assistance for some relocation and living costs until the
candidate can be self-supporting,
Assist the candidate to obtain professional development and supervision in public dentistry;
Assist the candidate to negotiate on-going employment with South West Healthcare in its
public dental health clinic
Budget – See Section 4.1
PCP Member Agency Participation:
The major project manager will be the SRSW Project, with co-ordination by Healthy Communities
and input by South West Healthcare, including any other key stakeholders mentioned above who
are participants of the PCP-South West.
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Priority for Action:
Vascular Disease Strategy:
Rationale/Evidence:
The South West region of Victoria shows a substantially higher than average rate of cardiovascular
disease (CVD) and diabetes for the state. For example Corangamite, Glenelg, South Grampians
and Moyne Shires ranked poorly between 71st and 73rd (out of 78 in the state) for CVD in men.
Diabetes rates in men were also much higher (4.7 to 5.3 per thousand) than the state average of 4.5.
For Australian indigenous people, the prevalence of Type 2 diabetes population is fourth highest
rate in the world and estimates of Type 2 diabetes in these populations vary between 10-30 percent
(National Health Priority Areas Report on Diabetes, 1999. The precise prevalence in the South
West indigenous population is unknown, however given the size of the local indigenous population
and number of local indigenous people known to have diabetes, the prevalence is much lower that
expected. This suggests an under reporting and under diagnosis of diabetes in the local indigenous
population.
Disability Adjusted Life Years
Disability Adjusted Life Years (DALYs) provide a snapshot of the relative importance of major
diseases to the total burden of disease in terms of life with disability in 1996. For males in
Warrnambool 2,051 DALYs were recorded. Cardiovascular disease accounted for 25% of DALYs,
(Figure 3). There were 1,547 DALYs recorded for males in Corangamite (S). Cardiovascular
disease accounted for 26% of DALYs. For males in Moyne there were 1,433 DALYs recorded,
where Cardiovascular Disease accounted for 26% of DALYs.
30%
Corangamite
Moyne
25%
Warrnambool
Percentage
20%
15%
10%
5%
0%
Cardiovascular
diseases
Cancer
Chronic
respiratory
diseases
Mental
disorders
Neurological
and sense
disorders
Unintentional
injuries
Causes
Figure 1: 1996 Major DALYs for South West Region males
and Sense Disorders 9%.
Females in the South West Region recorded fewer DALYs than did males. For females in
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Warrnambool 1,553 DALYs were recorded and cardiovascular disease accounted for 29% of these
(Figure 2). There were 1,286 DALYs recorded for females in Corangamite (S). Cardiovascular
disease accounted for 25% of DALYs. For females in Moyne there were 1,087 DALYs recorded,
where Cardiovascular disease accounted for 24%.
35%
Corangamite
Moyne
30%
Warrnambool
Percentage
25%
20%
15%
10%
5%
0%
Cardiovascular
diseases
Cancer
Mental
disorders
Neurological
and sense
disorders
Chronic
respiratory
diseases
Unintentional
injuries
Causes
Figure 2: 1996 Major DALYs for South West Region females.
Risk Factors:
By considering risk factors for ill health the potential health gains from addressing these factors can
be assessed. Figure 3 shows that Tobacco use was the most significant cause of Years of Life Lost
(YLL) and Years Lived with a Disability (YLD) for males in the Barwon South Western Region.
While Alcohol use provides some benefit, this is greatly outweighed by the harm caused. High
blood pressure, physical inactivity and high cholesterol are significant causes of YLL, with obesity
an important factor for YLD.
Tobacco
Alcohol benefit
Alcohol harm
Physical Inactivity
Low fruit and vegetable intake
YLL
Obesity
YLD
Illicit drugs
Occupation
Unsafe sex
High blood cholesterol
High blood pressure
-4.0 -3.0 -2.0 -1.0 0.0
% % % % %
1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0 11.0 12.0 13.0 14.0
% % % % % % % % %
% % % % %
MALE attributable burden (% of total DALYs)
Figure
3:
The
Burden
of
Disease
Males in the Barwon South Western Region 1996
Attributable
to
Risk
Factors
-
Figure 4: Presents the risk factors for females in the Barwon South Western Region. This shows in
terms of YLL, high blood pressure, physical inactivity and tobacco to be the most significant causes
of YLL, followed by tobacco use. factors in YLD.
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Obesity, physical inactivity and tobacco are significant factors in YLD.
Tobacco
Alcohol benefit
Alcohol harm
Physical Inactivity
Low fruit and vegetable intake
YLL
Obesity
YLD
Illicit drugs
Occupation
Unsafe sex
High blood cholesterol
High blood pressure
-5.0 -4.0 -3.0 -2.0 -1.0 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0 11.0 12.0 13.0 14.0
% % % % % % % % % % % % % % % % % % % %
FEMALE attributable burden (% of total DALYs)
Figure
4:
The
Burden
of
Disease
Females in the Barwon South Western Region 1996
Attributable
to
Risk
Factors
–
Understanding these risk factors and including them in a risk factor management training programs
will increase GP, practice nurse and outreach nurses and allied health capacity to deliver a systems
approach to risk factor management.
More recently Bunker et al (Medical Journal of Australia March 2003) have confirmed the role of
stress and social isolation as a risk factor in cardiovascular disease. Evidence based tools for the
identification of and intervention of depression and social isolation will be incorporated into risk
factor management training.
Ambulatory care sensitive conditions
A number of ambulatory sensitive conditions have been identified as a focus within the Public
Health Branch of DHS (Victorian Ambulatory Care Sensitive Conditions Study: Preliminary
Analysis, 2001).
These are conditions where appropriate ambulatory care can prevent
exacerbations leading to the need for hospitalisation and include:
 Angina
 Chronic Obstructive Pulmonary Disease.
 Asthma
 ENT infections
 Diabetes
(including access to podiatry services)
 Cellulitis
 Congestive Cardiac Failure (CCF)
 Dehydration and gastro
 Dental conditions
 Convulsions and Epilepsy
 Vaccine preventable diseases
Access to primary health care is important in addressing these conditions. However, primary health
care can be limited by a number of factors including:
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geographic factors such as distance, travel time and means of transportation
financial issues such as costs associated with health care and absence from employment
cultural issues such as language and cultural beliefs and
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organisational factors such as the availability of the right kind of care on a continuing basis
for those who need it.
The South West had the highest admission rate in the State for a number of these potentially
preventable conditions (out of 32 Primary Care Partnership catchments based on 1997-98 data).
Hospital admission rates for angina were the 7rd highest in the State and congestive cardiac failure
the 12th. (The Victorian Ambulatory Care Sensitive Conditions Study: Opportunities for Targeted
Interventions in Cardiovascular Disease and Chronic Obstructive Pulmonary Disease, DHS (2001).
In addition, South West was ranked 7th in the State for admission rates for complications of diabetes
(1999-00 data). This was also significantly higher than the State average (The Victorian
Ambulatory Care Sensitive Conditions Study: Opportunities for Targeting Public Health and
Health Services Interventions, DHS, Dec 2002).
In 2001-02, Ambulatory Care Sensitive Conditions accounted for 15,650 bed days or 50.4 beds at
85% occupancy. 60% of these bed days were used by people aged 70 plus (Figure 5).
Complications of diabetes were a factor in 40% of bed days associated with Ambulatory Care
Sensitive Conditions.
6000
5000
Bed days
4000
3000
2000
1000
0
00-19
20-39
40-59
60-69
70-79
80 plus
Age group
Figure 5: 2001-02 Bed days by age group for Ambulatory Care Sensitive Conditions in the South
West (and Colac Otway South).
Local knowledge of vascular diseases risk factors:
In 2002 the Primary Care Partnership South West in partnership with the University Department of
Rural Health (Warrnambool ) developed a cardiovascular disease and diabetes risk factor health
knowledge quiz. Consumers were offered prizes to complete the quiz and over 800 responses
were recorded. An analysis of the results clearly demonstrates a lack of community understanding
of the risk factors to vascular diseases.
In summary, for the benefits of exercise, less than 50% of respondents understood this and only
60% knew that physical inactivity increased the risk of a heart attack. Eighty percent realised that
smoking was a risk factor for an acute myocardial infarct however, the role that diabetes plays in
developing heart disease is not well known. Less than 50% of respondents linked diabetes with
cardiovascular disease. The role of high blood pressure and heart disease was better understood
with 80% aware of the association. The role of obesity in diabetes was well recognised with 80%
awareness.
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This brief summary highlights areas of health education that should be tackled it also demonstrates
that some of the current programmes are not achieving levels of public awareness that might be
expected.
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Problem Definition: High prevalence of vascular diseases in South West Victoria.
Target Group:
Indigenous people accessing the Kirrae Aboriginal Controlled Health Service in Framlingham and
the Gunditjmara Aboriginal Controlled Health Service in Warrnambool.
Goal:

To empower the local indigenous communities in the early detection, prevention and
management of type 2 diabetes
Objectives:
 To increase access to an appropriate model of diabetes management & care coordination
 To increase the capacity of Aboriginal Health Workers to manage diabetes in their local
community
 To increase local knowledge about the prevalence of type 2 diabetes in the local
Aboriginal Controlled Health Services
 To increase mainstream services responsiveness to the diabetes management needs
of indigenous people
And to complete 2002/03 activities:
 Complete the GP based vascular diseases register, recall and reminder system and
establish audit cycles to allow for continuous quality improvement in vascular diseases
management
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Complete the evidence based multi-disciplinary primary and secondary prevention
training for health professionals
Demonstrate the sustainability of the three cluster models for diabetes co-ordination
developed by the Integrated Disease Management Project
Establish primary care settings systems approach for the early detection and prevention
of type 2 diabetes
Solution Generation:
2003/2004 Strategies:
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To develop a local Aboriginal model of integrated disease management for diabetes
To engage and empower the aboriginal community, their GP’s and health workers to
develop the local diabetes model
To promote the evidence based guidelines for diabetes prevention and management
amongst the Aboriginal community, their GP’s and health workers
To develop culturally appropriate resourced and programs to support local diabetes
prevention and management
To work in partnership with local mainstream services to enhance their delivery of
culturally appropriate diabetes services to the local Aboriginal communities
Evaluation
2003/2004 Reach:
 Number indigenous people recruited to the diabetes register
 Number health workers attending training
 Number community members attending formal and opportunistic education and information
sharing
 Number of indigenous people accessing of specialist mainstream diabetes services
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Impact:
 Aboriginal Health Worker and indigenous peoples knowledge and confidence in diabetes
management techniques
 An active and up to date diabetes register
Integration with Service Co-ordination:
A process for initial contact, needs identification, referral and service information will be developed
as a part of this project using the Service Co-ordination tools, policies, processes and systems.
Support & Resources:
See Budget Section 4.1
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Rationale/Evidence:
Department of Human Services policy
Problem Definition: Service Coordination
Target Group:
The project spans the South West Region and includes all member agencies in PCP South West and
PCP Southern Grampians and Glenelg.
Goal:
The overall goal of the Service Coordination project is to support agencies and services to work
together to achieve a consistency of practice and service delivery so that consumers have
appropriate and timely access to services, needs identification and subsequent care.
Objectives:

To develop a regional service coordination model for South West Victoria which is
inclusive of Department of Human Service policy, local needs and mores and identified
best practice.
Specifically:

To develop and enhance the working relationships of agencies in both PCP South West
and the Southern Grampians and Glenelg PCP.

To develop and adopt practice, processes, protocols and systems for service
coordination tool implementation in the South West

To demonstrate practice, processes, protocols and systems development complies with
the Health Records Act and Information Privacy Act

To provide support for the implementation of service coordination tools in a manual
form and to develop the infrastructure to support implementation in electronic form.

To decide on a suitable Electronic Services Directory and to determine the way in which
the Service Directory can support service coordination in the South West

To develop workforce development programs to assist and support service providers
through the change management process and to participate fully in improved service
coordination

To include consumers in Service Coordination initiatives

To develop a framework for the ongoing monitoring and evaluation of the regional
service co-ordination model.
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Solution Generation
Strategies:
 Maintain the Service Coordination Working Party which is inclusive of PCP member
agencies. Review the role of the group in the context of ongoing governance and
sustainability
 Review the membership of Service Provider network meetings across PCP South West and
Southern Grampians and Glenelg to ensure membership is appropriate and inclusive
 Establish task groups e.g. the e Referral sub group (of the Service Coordination Working
Party) to continue draft protocols development using best practice references, local ways of
working and relevant legislative requirements e.g. privacy
 Use agency clusters to pilot implementation of specific protocols e.g. referral
 Work closely with the SWARH and software providers and agencies to:
-facilitate the integration of service coordination tools into existing software systems
-further develop an e referral system around existing agency databases
-influence software providers and the DHS to expedite agreement around a common
messaging system
 Provide a series of regional service coordination workshops to further develop agency
staff’s understanding of service coordination aspects. Workshops will include the
application of PPPs in agency settings.
 Engage and consult with PCP South West Consumer Reference Group and the Southern
Grampians and Glenelg Consumer Engagement Reference Group in the process of protocol
development.
Evaluation:
Reach









- Current (June 2003)
85 % agencies represented on the Service Coordination Working Party
100% of interagency meetings reviewed
85% agencies using the service coordination tools
At least two (2) agency cluster groups per protocol and the South West Consumer Reference
Group involved in trailing Initial Contact, Initial Identification, Referral and Interagency
Care Coordination.
40 % of agencies engaged in e referral
20% of agencies engaged in import /export of data
85 %agencies represented at work force training workshops
50 % of agencies will be using preferred model of service directory
A framework for monitoring and evaluation from a system perspective will be in place
Impact:







Agencies will be familiar with each other and trust each others judgement when referring
Interagency meetings will have appropriate representation and the breadth of client needs
will be covered
Agencies will take on board protocols developed for the South West and will conduct the
activities of service coordination in a common way.
The South West Consumer Reference Groups will know what to expect from a coordinated
service delivery
The process of referral for some agencies will be quicker and more streamlined
Some agencies will experience efficiencies as a result of import/export functionality and in
turn will be able to redirect resources to client care
Staff at most agencies will have the knowledge and skills to assist clients to obtain their care
needs
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Outcome:
It is anticipated that the period 2003-4 will be a period of significant service coordination activity
and change. It is also anticipated that it will take this period of time to implement many of the
changes. Given this, it would seem that assessment of outcomes at this point is inappropriate.
Support & Resources
The Service Coordination reform in the South West is coordinated by 1 EFT Project Coordinator
and is supported by staff participating from member agencies. A Project Officer from Southern
Grampians and Glenelg PCP coordinates specific projects such as privacy and service directories.
The PCP South West Administration Officer and the Executive Officer provide additional support to
the overall project.
Both PCP South West and Southern Grampians and Glenelg have funds to assist agencies to
embrace the reform and some agencies have received assistance via their programs. It is also
expected that all agencies have an ‘in kind’ contribution.
A sub regional meeting has been scheduled in the very near future to determine areas/activities
requiring funding and to determine appropriate use of existing funds.
Budget – See Section 4.1
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Priority for Action:
Access to Information about Services – Consumer Project
Rationale/Evidence:
There are four main reasons* why consumer participation is important in primary care and other
health settings:
 Participation is an ethical and democratic right
 Participation improves service quality and safety and helps gain health service accreditation
 Participation improved health outcomes
 Participation makes services more responsive to the needs of consumers
* Source: Department of Public Health, Flinders University and the South Australian Community
Health Research Unit.
This work for 2003-04 represent the third year in the development and implementation of a strategy
to improve consumers access to information about services. Consumers with agreement from
service providers, have identified that piloting primary care settings as service “information hubs”
is an important strategy to develop and implement in the next stage of this project.
Problem Definition: Consumer difficulty when accessing information about services
Target Group: General Practice settings; Lyndoch, Brophy, Life Line, Timboon Health,
Moyne Health Service
Goal:
To develop and pilot the establishment of “information hubs” in local and existing
Primary care settings
Objective:
To increase consumer access to service information in primary care settings
To evaluate the ‘hub’ to determine sustainability
Solution Generation:
Strategies




Undertake focus groups with three GP practices, participating agencies and the Consumer
Reference Group to determine the feasibility of general practice being a “hub” for service
information
Trial the delivery of service information in general practice
Make recommendations for service information access in General Practice
Provide service information access training to the five member agencies who have expressed
interest in participating ie (Lyndoch, Brophy, Life Line, Timboon Health, Moyne Health
Service)
Evaluation:
Reach




Number of information hubs developed
Number of service providers trained
Number of consumers participating in development of site for ‘hub’ and service provider
training
Number of consumers accessing ‘hubs’ in a defined period of time
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
Number of consumers satisfied with the ‘hub’
Impact:

Sustainable ‘information’ hubs in primary care settings
Integration with Service Co-ordination:
This project contributes to the regional Service Co-ordination strategy. The information hubs
developed for the primary care settings as described above will utilize the Service Co-ordination
tools, policies, practices, processes and systems for client contact and referral.
Support & Resources:
See Budget – Section 4.1
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Priority for Action: Falls Prevention
Foothold on Safety
Rationale/Evidence:
Falls are common amongst older Australian living in their own homes. It has been acknowledged
that falls in older Australians are a major public health problem.
The demographics of the PCP –South Wets catchment demonstrate that there is a higher
proportion of people over 65 years compared with the state average.
The primary issue for falls is the injury sustained treatment and recovery and possibility of
hospitalisation. Falls have an impact on the quality of life in older people regardless of injury.
People lose independence through loss of confidence and anxiety. Injury directly relates to loss of
mobility and physical and mental health issues.
The challenges for health providers is to raise awareness of extrinsic (environmental/situational)
and intrinsic (host) factors that contribute to falls risk. The challenge extends also to the
identification of high risk groups and implementation of strategies to reduce falls risk and improve
quality of life.
The Footholds on Safety Project is a three year initiative funded by the Victorian Department of
Human Services and auspiced by Lyndoch Warrnambool Inc. A project steering group has been
established to support the project co-ordinator and an existing group, the South West Falls
Intervention Team receives project reports and acts as its advisory group.
Problem Definition: Falls Prevention
Target Group:
This project will target the older population group living in their own homes (including hostels,
supported residential services, independent living units) throughout the PCP catchment area. This
includes three functional groups of older people:
1) Vigorous group (Avg 78 years)
2) Transitional group (Avg 81 years)
3) Frail group (Over 86 years)
While the project will be targeting the older population in general, a more specific focus will be on
those shown to have an increased risk of falling.
Goal:
To reduce the risk and incidence of falls and the severity of injuries from falls among older people
living in their own homes in the PCP-South West catchment area.
Objectives:
Using the principles of Strength Training for falls prevention, the objectives of this foothold on
safety project are to:
 Increase community recognition of falls as a ‘whole of community’ responsibility.
 Increase community understanding that falls are not an inevitable part of growing older.
 Integrate into practice falls prevention strategies and community activities that will be
sustained beyond the life of the life of the project.
 Increase the proportion of older people who actively participate in reducing their risk of
falling and as a consequence enjoy an independent and healthy lifestyle.
 Increase the safety of local environments for current and future generations.
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Solution Generation:
Strategies:













Establish network/alliance of health and social support services, care and volunteer provider
organisations in region
Develop regional, best practice framework for Falls Prevention
Establish and implement standardised risk assessment tool and intake protocols for regional
use by health and community workers
Develop and implement community awareness plan
Develop resources on local exercise and physical support programs, for older people
Improve access to education and training for providers
Provide a focus and identity for ‘Falls Prevention’ and promote availability of local
information to the target group and the wider public
Promote awareness through media, public events, health centres/gymnasiums, business
houses
Facilitate screening and data collection on falls
Analyse information and identify areas of intervention
Promote regular home safety monitoring and follow up
Facilitate home safety assessments by OT’s for older persons at risk
Strengthen safety monitoring capacities of community
Evaluation:
This Foothold on safety Phase 4 Project will be evaluated using the Generic evaluation assessment
system (G.E.A.S). this would provide quantitative process and impact data on the project. The
following areas have been identified using the G.E.A.S. “Monash University Accident Research
Centre”, and would be highlighted throughout the project:







Resource Development
Building Partnerships
Social Marketing
Education & Training
Screening or individual risk assessment
Regulations, policies, protocols, practices
Fall and injury data
Integration with Service Co-ordination:
This project will utilize the Service Co-ordination Tools for client contact; referral; service
information; needs identification including living arrangements profile; functional profile; health
behaviours profile; health conditions profile and psychosocial profile.
Support & Resources:
This project has been funded for a period of three years, the Auspise Agency is Lyndoch
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Priority for Action:
Domestic Violence/Family Violence
Rationale/Evidence:
The strategies of the PCP-South West have been identified as priorities in the Healthy Communities
Project. In the report Domestic Violence/ Family violence was identified as a priority in the PCP
Integrated Health Plans, the five Municipal Public Health Plans and the regional Community Safety
Plan.
Domestic/Family violence is not an issue that PCP-South West will address in isolation and the
Healthy Communities Steering Group will provide the forum for the three planning groups to coordinate implementation strategies. The task of co-ordinating the implementation of a regional
strategy across three planning entities is new work for the region.
The PCP Southern Grampians and Glenelg and PCP-South West held forum with Domestic
Violence stakeholders in April 2003 and agreed to work together on this strategy. The summary of
issues identified at the forum include:






Lack of good data on family violence as a presenting issue across the service sector and
therefore of the issues facing service providers
Lack of confidence and skills in the general service sector relevant to family violence. This
includes the skills to recognise signs associated with family violence, knowledge and ability
to respond appropriately and to make effective referrals to the specialist services.
Lack of resources in the family violence services to respond to existing need (consumers) or
to work with, support and train the broader service sector.
The need to look at prevention and early intervention to reduce the incidence and impact of
family violence and not just the crisis intervention approach.
Importance of the recognition of family violence as a priority on the government and agency
agenda.
Recognition that there are varied cultural and target group expectations and there is not a
“one size fits all” response that can be applied.
Problem Definition: Need to increase local capacity to address domestic/family violence
Target Group: Domestic/Family Violence Stakeholders
Goal:
To increase the capacity of the primary care system and community to prevent, identify and
respond to domestic and family violence
Objective:
Contribute to the development of the Domestic Violence/ Family Violence regional strategy with
the PCP Southern Grampians Glenelg and Healthy Communities Strategy including but not limited
to the identification of local needs and opportunities for training, education and support for the
community; service providers; victims and perpetrators;
Solution Generation:
At the PCP-South West and PCP Southern Grampians/Glenelg domestic/family violence forum,
the support for developing a training approach was recognised however, this could not be the sole
response and that significant issues included:
 Unless the objectives of training were clearly identified there could be problems in
increased referrals to an already overloaded system
 Workers could be put at risk of violence themselves from aggrieved men
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
Workers need to be supported by their agencies that understand the issues and are
able to provide support.
It was agreed that a valuable first task for the PCPs to take would be to work with their member
agencies and encourage them to develop workplace policies on domestic/family violence.
The newly appointed Executive Officer for the Healthy Communities implementation will be a
valuable resource in collaboration with other PCP staff and the specialist domestic/family violence
agencies.
A Forum of member agencies was considered to be an important first step in this process
This progress will be reported to the Healthy Communities Project strategy and integrated with the
work of the Healthy Communities Project, and the implementation of the Municipal Public Health
Plans and the Regional Community Safety Plan.
Evaluation:
Reach:
 Number of PCP member agencies participating in the forum and training

Mix of stakeholders participating in the forum and training
Impact:
 Number of PCP member agencies with active workplace policies on domestic /family
violence

Number of staff of PCP member agencies with reported increased confidence and skills in
to recognise signs associated with family violence, knowledge and ability to respond
appropriately and to make effective referrals to the specialist services.
Integration with Service Co-ordination:
The introduction of consistent needs identification, referral and care planning tools will assist with
improved data collection across Domestic Violence/Family Violence service providers. These
service are not currently mandate to implement the tools and the true value of these tools will start
to be valuable in this area when they are extended to include the whole service sector. An
examination of the current tools and their ability to identify risk and include issues specific to
family violence would be valuable and could be referred to the SW Service Coordination Working
party.
Support & Resources:
See Budget – Section 4.1
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Priority for Action:
Seeking funding for oral health projects identified as priorities from the PCP-SW Oral Health
Working Party.
Rationale/Evidence:
Background:
Community consultation during the Healthy Communities Project showed widespread concerns
about the limited availability, or absence of a number of health services including allied health;
dentists, general practitioners and medical specialists. In developing the 2002/03 Community
Health Plan, the PCP-South West acknowledged that it could not address all areas and that it
would focus on oral health promotion and improving access to dental health services.
A working group was formed of private and public dentists to determine priorities for oral health
promotion. The priorities identified by this PCP-South West working group include:
- Oral Health education for older people and their carers
- Educating the community about water fluoridation as well as non-water supplies of fluoride
- Oral Health education for pre-school and primary school children and their parents
In the 2003/04 year an activity of the PCP – South West will be to seek external funding to
commence these initiatives:
OPTION 1 Oral Health education for older people and their carers
Rationale:
Poor oral health in old age can make general health worse. A report compiled by Martin Dooland
(CEO DHSV) in April, 2000, found that it was “extremely likely that the large number of older
Australians were prematurely losing their independence and being admitted to nursing homes,
hostels or acute hospitals because of degraded diets, caused or aggravated by poor oral health”.
In the Department of Human Services report Promoting Oral Health 2000-2004, Strategic
Directions and Framework for Action, it is predicted that by 2009, older people will have more
than one million dental caries that will need restoration or extraction. It also states that more than
90% of people aged between 60 and 69 have periodontal disease.
While many older people are keeping their natural teeth for longer, they still experience poor oral
health. As people age there is a greater risk of tooth decay and gum disease.
Goal:
To improve the oral health of older people living in South West Victoria through targeted
education workshops.
Objectives:
 Develop personal skills in order to reduce the incidence of dental decay, oral cancers and
gum disease in the elderly living in South West Victoria;
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 Promote the relationship between good oral health and good social and emotional health
and well being;
 To promote the use of appropriate fluoride therapies to the target group
OPTION 2 Educating the community about water fluoridation as well as non-water
supplies of fluoride
Rationale:
The use of water fluoridation is a long established and effective method of reducing dental caries
and that children in unfluoridated areas have poorer oral health than those in fluoridated areas.
An accurate community knowledge campaign is required in the South West to determine the
community’s acceptance or otherwise of water fluoridation.
In the process, education about non-water supplies of fluoride would facilitate improved access to
fluoride.
Goal :
To conduct an accurate and informative community education campaign about water fluoridation
and non-water supplies of fluoride in South West Victoria, with the aim of determining the
community’s acceptance of water fluoridation.
Objectives:
 To increase community capacity to make an informed choice about water fluoridation;
 To improve the community’s understanding of the facts about water fluoridation;
 To create informed community debate about water fluoridation;
 To determine the community’s collective position on water fluoridation.
 To facilitate appropriate access to fluoride
OPTION 3 Oral Health education for pre-school and primary school children and their
parents.
Rationale:
In 1997, 12% of 5 year old Victorian children had greater than 5 decayed missing or filled teeth.
Reducing this figure would reduce the ongoing cost of dental care and would improve the health
and wellbeing of these children.
Goal:
 To reduce the incidence of dental caries and periodontal disease amongst children (0-12 years)
living in South West Victoria.
Objectives:
 Educate parents about oral health care for their children
 Educate kindergarten teachers, family daycare operators, nursing mothers, families and carers
and staff at long day care centres about appropriate oral health care for children aged 0-6 years
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 Adapt existing DHS and Queensland Health resources into education material for parents, as
well as training workshops for kindergarten teachers, family daycare operators and staff at
long daycare centres
These projects demonstrate a commitment to evidence-based oral health promotion practices, and
the health outcomes outlined in the DHS Strategic Directions and Framework for Action (DHS
1999) and the Resources for Planing (DHS 2000). The objectives and methodology reflect the
action areas of the Ottawa Charter.
Problem Definition: Need to seek additional health promotion resources
Target Group:
 Funding sources for oral health for example DHS; DHSV; Philanthropic funds
Goal:
 Obtain funding to undertake new initiatives based upon the priorities established by the
PCP-South West Oral Health Working Party. These initiatives include: fluoridation;
preschool oral health promotion and ongoing aged care training
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Integrated Health Promotion Projects
Priority for Action:
Depression, social isolation and lack of quality support for vascular disease.
Rationale/Evidence:
Evidence:
Comorbidity of physical illness and depression is common, disabling, associated with a significant
increase in mortality and is often under-diagnosed in both tertiary and primary care setting. People
with a physical illness with a co-morbidity of depression can have difficulty negotiating the health
care system and therefore timely treatment can be denied which leads to a significant increase in
both direct and indirect healthcare costs.
With regard to vascular diseases, a multidisciplinary Working Group of the National Heart
Foundation of Australia undertook a review of systematic reviews of the scientific evidence relating
to major psychosocial risk and cardiovascular disease. The Group concluded that there is strong and
consistent evidence of an independent and causal asocial between depression; social isolation and
lack of quality social support in both the causes and prognosis of cardiovascular disease (Bunker et
al Medical Journal of Australia 2003; 178: 272-276).
Local Health Status:
The Disability Adjusted Life Years which provides a snap shot of the relative importance of major
disease to total burden of disease in terms of life with a disability showed that cardiovascular
disease was ranked No 1 for men and women in Warrnambool, Moyne and Corangamite.
Local Ambulatory Sensitive Conditions:
The PCP South West catchment has the highest admission rate in the State for a number of these
potentially preventable conditions (out of 32 Primary Care Partnership catchments based on 199798 data).
Hospital admission rates for angina and congestive cardiac failure were the 7th and 12 th highest
respectively that the State average. (The Victorian Ambulatory Care Sensitive Conditions Study:
Opportunities for Targeted Interventions in Cardiovascular Disease and Chronic Obstructive
Pulmonary Disease, DHS (2001).
In addition, South West was ranked 7th in the State for admission rates for complications of diabetes
(1999-00 data). This was also significantly higher than the State average (The Victorian
Ambulatory Care Sensitive Conditions Study: Opportunities for Targeting Public Health and
Health Services Interventions, DHS, Dec 2002).
Problem Definition:
Increased rates of admission to hospital for preventable hospital admissions, especially in relation
to vascular diseases.
Target Group: People at high risk of admission/readmission for vascular diseases.
Goal: Improve social and health support systems for people to reduce preventable hospital
admissions
Objectives:
 To increase community and health worker awareness of depression, social isolation and lack
of quality support as independent risk factors to vascular disease.
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

To increase opportunities for social connectedness and access to quality support in the target
population
To improve health worker capacity to systematically screen for depression and social
isolation, and lack of quality support services refer and follow up with the target population.
Solution Generation :
Strategies :
 Community discussion to identify barriers and enablers to improved recognition and referral
of depression, social isolation and lack of quality support in the target group
 The Primary Mental Health Team and Aspire will develop and deliver training program/s to
increase awareness amongst health workers and the community.
 A service co ordination model for screening, referral, intervention and connection will be
developed by the project team including representatives from the Otway Division of
General Practice (ODGP), the ODGP psychologist, the Primary Mental Health Team, PCP
members and PCP service co ordination staff.
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Evaluation:
Reach:







Number of people screening with validated tool
Number agencies participating in developing service co-ordination system for referral and
intervention
Number referrals
Number of people receiving health information
Consumer tracking and satisfaction with referral process
Number health workers and consumers participating in increasing awareness of depression,
social isolation and role of quality support services
Number settings and participants in community development activity to address social
connectedness and isolation
Impact:




Increased knowledge and skill of health workers and the community to identify cases of
depression, social isolation and lack of quality services
Increase in number of the target population referred for depression, social isolation or lack
of quality support services
Increased co ordination between General Practitioners, the Primary Mental Health Team
and Primary Care Providers
Increased opportunities for social connectedness for target group
Integration with Service Co-ordination:
An objective of this project is to develop a service co-ordination model and this will include
components of the service co-ordination tools for example: Privacy Brochure; Consumer Consent;
Consumer Information; Summary and Referral; Supplementary Profiles and the Consumer Service
Co-ordination Plan ( ie care plan).
Support & Resources:
See Budget – Section 4 (Page 55)
Capacity building strategies have been identified and will focus on : General Practitioners;
Primary Care Nurses, Primary Mental Health Team, acute care staff, allied health, counselors,
practice nurses, and rehabilitation specific staff. Training will include an update of the evidence;
use of tools for the identification of people who suffer from depression, and/or are socially isolated
and/or lack quality support; and use of the service co-ordination model
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Integrated Health Promotion Program Summary Grid
Depression, social isolation and lack of quality support for people with vascular disease ( CVd;
stroke, diabetes) Program Goal: Population Target Group/s: People at risk for admission/readmission for vascular diseases
Program
Objectives
Objective 1:
To increase community and
health worker awareness of
depression, social isolation and
lack of quality support as
independent risk factors to
vascular disease
Health Promotion
Interventions & Capacity Building
strategies1
Estimated
Impacts2
(Qualitative &/or
Quantitative)
Estimated3
Reach
Timelines
& by which agency4
Interventions
Social marketing /Health information
Health education and skill development
Community action
Workforce Development
Increased
knowledge and skill
of health workers
and the community
to identify cases of
depression, social
isolation and lack of
quality support
services
Five training sessions for GP’s;
Primary Care Nurses; Diabetes
Educators, acute care staff
and allied health, councillors,
practice nurses, rehabilitation
staff; counsellors
The South West Primary
Mental Health Team will
develop and deliver training
to health workers across the
PCP-SW membership during
2003/04
Four training session to the
community will be provided
targeting high risk population
settings
ASPIRE will deliver training
to the community during
2003/04
Strategies
Identification of barriers and enablers to
improved recognition and referral of
depression, social isolation and lack of
quality support services
PCP-South West GP Liaison
Officer will co-ordinate
training, increase GP
participation and access
training resourced for social
isolation, access to quality
supports and the application
of the health belief and
trans-theoretical models of
behaviour in the target
population
The development, delivery and evaluation
of training programs to increase awareness
amongst health workers and the community
Total Budget per Objective:
Salary and wages $21,906 Consumables $6,666
1
Please refer to the document Integrated Health Promotion Interventions and Capacity Building Strategies November 2002 (This is an interim resource developed whilst
the Health Promotion Guidelines are being updated. It can be down loaded from www.dhs.vic.gov.au/phkb under Health promotion in Primary Care Partnerships) which
describes these interventions and strategy types. An appropriate mix of interventions and strategies should be documented, to address the stated objective (solution
generation in section 2.3 above). PCPs are only required to fill in interventions/strategies that are relevant; all other interventions/strategies categories can be deleted.
2 Estimated Impacts (Qualitative &/or Quantitative): Planning requires the development of impact indicators to measure the achievement of program objectives. PCPs are required to identify intended
impacts as part of their planning process and report against these in 2003-2004.
3 Estimated Reach: Planning requires the development of process indicators for each program. However, the Department only one type of process indicator-Reach to be documented
in the health promotion summary grid. For further information please refer to the document Process Evaluation-Reach that can be downloaded from www.dhs.vic.gov.au/phkb under
Health promotion in Primary Care Partnerships.
4 Timelines& By Whom: Timelines for implementation need to be identified as well as the agency responsible for carrying out the action.
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2003 / 2004 COMMUNITY HEALTH PLAN
Program
Objectives
Health Promotion
Interventions & Capacity Building strategiesi
Estimated Impactsii
(Qualitative &/or Quantitative)
Estimatediii
Reach
Interventions
Community action
Settings and Supportive Environments
Two consumer lead strategies to
increase opportunities for social
connectedness and access to quality
support are sustainable
Four
community
discussions
involving at
least five
agencies
Objective 2:
To
increase
opportunities
for
social connectedness
and access to quality
support in the target
population
Strategies
Undertake community discussion in existing groups eg cardiac
rehabilitation; heart; stroke, mental health or diabetes support
groups
Two
consumer
lead
strategies
involving at
least 25
consumers
Identify barriers and enablers for social connectedness and
access to quality support
Pilot two consumer lead strategies to increase social
connectedness and access to quality support. (The Mortlake
community has expressed a keen interest and is likely to
participate as a pilot site).
Total Budget per Objective:
Salary and wages $21,906 Consumables $6,666
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Timelines
& by which
agencyiv
The South West
Primary Mental
Health Team,
ASPIRE, primary
care staff of
member agencies
and the PCP GP
liaison officer will
facilitate
community
discussion and coordinate the pilot
consumer
strategies during
2003/04
Program
Objectives
Health Promotion
Interventions & Capacity Building strategies5
Estimated Impacts6
(Qualitative &/or
Quantitative)
Estimated7
Reach
Timelines
& by which
agency8
Workforce Development
Organisational Development
50% of high risk
people consent to
participating in
screening for
depression; social
isolation or lack of
quality support
services
100 people screened
PCP GP liaison
officer will coordinate this
strategy during
2003 -2004
83 percent of health
workers trained can
implement the service
co-ordination model for
depression, social
isolation and lack of
quality support
services
25 health workers
contribute to the
development of the service
co-ordination model
Objective 3
To improve health
worker capacity to
systematically
screen for
depression, social
isolation and lack of
quality support
services
Strategies
Provide training using validated tools to health workers
including GP’s; primary care nurses; acute care staff; allied
health and diabetes educators
Develop a service co-ordination model including screening;
health information for depression, social isolation and lack of
quality support services; client contact; needs identification;
referral; service co-ordination planning ( care planning) and
access to information about services
Total Budget per Objective:
Salary and wages $21,906 Consumables $6,666
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30 health workers trained
25 referrals
100 people receive health
information
25 health workers with the
capacity to implement the
service co-ordination
model
Integrated Health Promotion Project
OPTION 2
Priority for Action:
Eat Well Be Active – A Community Building Approach
Background:
PCP-South West has been approached by a Deakin University/Department of Human Services
(DHS) consortia to form a partnership with them to develop a proposal for the Eat Well Be Active
round of funding to be announced in the June 2003 –04 financial year. This funding forms part of
the DHS 10 million dollar investment in obesity prevention over the next four years.
PCP-South West convened a meeting with the consortia and local members to gauge local interest
in pursuing this partnership and in developing a collaborative submission ready for when the
funding round is announced. The meeting was attended by twenty two participants with
representation from several sectors including: local government, acute; disability; education;
primary care and general practice.
At the meeting, there was agreement to proceed with the consultative process in order to develop a
submission.
This approach requires endorsement by the PCP Management Team and consideration for 20032004 PCP Health Promotion funding.
Rationale / Evidence:
Physical activity and healthy eating are two of the most important determinants of health and key
determinants in preventing overweight and obesity. Their impact is quantified in the Community
Profile “ Risk Factors” .Figure 12 in this previous section shows that physical inactivity and obesity
are important factors for Years of Life Lost (YLL) and Years Lived with a Disability (YLD) for males
and females living in the Barwon South Western Region. This information highlights the capacity
for a focus on physical activity and nutrition (healthy eating) to impact across other risk factors
including hypertension; high blood pressure; insufficient intake of fruit and vegetables; blood fats;
Body Mass Index and waist to hip ratio.
In addition to individual health benefits, this project will seek to explore and measure the
opportunity and capacity for physical activity and healthy eating initiatives to contribute to building
social capital and creating health promoting environments. A supportive and health promoting
community can be described as one which facilitates and enables social connectedness,
inclusiveness, appropriate support and volunteerism, a sense of belonging, and recognition of the
importance of the family.
Problem Definition: Prevalence of obesity in school children
Target Group:
 PCP-SW member agencies and stakeholders participating in the initial Eat Well Be Active
partnership meeting
Goal:
 To receive funding for an Eat Well Be Active Project in order to improve the health and
well being of individuals and strengthening communities
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2003 / 2004 COMMUNITY HEALTH PLAN

Enhance social and cultural environments that support and endorse healthy eating and
physical activity
Objectives: of the Eat Well Be Active Project will be to:




Enhance physical and economic environments that support and enable healthy eating and
physical activity
Increase social capacity and enhance health promotion aspects of the local community
Increase community and individual awareness if the importance, benefits and opportunities
for healthy eating and physical activity
Increase the proportion of the community adopting healthier approaches to eating and
adequate physical activity
Integration with Service Co-ordination:
To be determined during submission writing.
Support & Resources:
Project Management:
The direct management and implementation of the project will be the responsibility of the auspice
agency. This activity will be supported by the local steering committee, with broad community
representation. The steering committee will be responsible for deciding the allocation of funds and
will report to the Department of Human Services.
Budget:
A budget will be required for:
1. Development of the submission ( PCP). (See Budget Section 4.2)
2. Project ( DHS funding or DHS funding with PCP contribution )
3. Evaluation ( DHS funding or DHS funding with PCP contribution)
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PCP –SOUTH WEST BUDGET SUMMARY *
4.0
Income:
2002-2003 unexpended
2003-2004 PCP Planning
2003-2004 PCP Service Co-ordination
2003 –2004 Integrated Health Promotion
2003-Dec.2003 Integrated Disease Management
2003-2004 Commonwealth Indigenous Project
Pharmaceutical Company Sponsorship
$ 495,000* ( *interest acknowledged but not claimed
from South West Healthcare)
$ 70,000
$ 30,000
$ 90,000
$ 75,000
$ 60,000
$ 3,200
TOTAL:
$ 823,200
Expenses:
PCP generic expenses across all strategies
PCP Strategy specific expenses
PCP-South West review of governance, role and
function
Healthy Communities Strategy
Vascular Disease Strategy including work
remaining on 202-2003 Integrated Health
Promotion Projects
Service Co-ordination Regional Strategy
Access to Information About Services – Consumer
Project
Footholds on Safety
Domestic Violence
Oral Health
2003-2004 Integrated Health Promotion Project Depression, social isolation. Lack of quality
support in people with vascular disease (CVD,
stroke, diabetes)
2003 –2004 Integrated Health Promotion Project Eat Well Be Active
$106,236
TOTAL:
$ 823,200
$ 26,883
$ 38,813
$235,424
$186,300
$81,540
$ 5843
$10,668
$ 5,844
$ 38,577 pcp salary & wages
$ 47,146 participating agency salary ,& wages,
training & consumer pilot project
$ 39,926 ( (in kind for submission including local
collaboration & development )
DETAILED BUDGET WORKINGS FOLLOW INCLUDING:
1.
2.
3.
4.
Staff EFT distribution across PCP- South West strategies
Salary and wages costs across PCP- South West Strategies
PCP generic costs across all strategy areas
PCP- South West strategy specific budgets
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1.0
Staff
Staff EFT distribution across PCP- South West Strategies:
Judy
Julie
Jacinta
Dr Ann
Nichols
Hall
Ermacora
Dunbar
Total EFT
1 EFT
0.84
EFT
PCP-South West
review of
governance, role
and function
Healthy
Communities
Strategy
Vascular Disease
Strategy
0.05 EFT
( 1 day per
month)
0.025
EFT
0.05 EFT
0.025
EFT
0.2 EFT
(1 day per
week)
0.1 EFT
(2 days per
month)
0.05 EFT
0.19 EFT
Service Coordination
Regional Strategy
Access to
Information
About Services –
Consumer
Project
Footholds on
Safety
Domestic
Violence
Oral Health
Depression, social
isolat. lack of
quality support in
people with
vascular disease
(CVD, stroke,
diabetes)
Eat Well Be
Active
2.0
0.6 EFT
Frank
Blake
( IDM)
Coleraine
/Casterton
Clinic
( IDM)
0.4 EFT
FOR 6 MO
Camperdn
Clinic
( IDM)
Cambourne
Clinic
( IDM)
0.85 EFT
Indigenous
community
Worker
( IDM)
0.5 EFT
1 EFT
0.2 EFT
FOR 6
MONTHS
0.2 EFT FOR 6
MONTHS
0.8 EFT
0.5 EFT
0.4 EFT
0.2 EFT
0.2 EFT
0.05 EFT
0. 2 EFT
0.2 EFT
0.5 EFT
Margaret
Sinnott
0.5 EFT
0.05 EFT
0.9 EFT
0.1 EFT
0.1 EFT
0.05 EFT
0.05 EFT
0.1 EFT
0.05 EFT
0.2 EFT
0.2 EFT
0.2 EFT
0.2 EFT
0.1 EFT
0.1 EFT
Salary and Wages Costs across PCP- South West Strategies
PCP Strategy
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Total salary & wages
Page 61 of 67
2003 / 2004 COMMUNITY HEALTH PLAN
PCP-South West review of governance, role and
function
Healthy Communities Strategy
Vascular Disease Strategy
Service Co-ordination Regional Strategy including
Access to Information About Services – Consumer
Project
Footholds on Safety
Domestic Violence
Oral Health
Depression, social isolat. lack of quality support in
people with vascular disease (CVD, stroke, diabetes)
Eat Well Be Active
TOTAL
(inc @ 20% oncost )
$ 5,843
$ 9,623
$14,0131
$89,300
$54,490
$5,843
$10,668
$5,844
$38,577
$29,926
$390,245
3. PCP generic costs across all strategy areas
Telephone/ Mobiles x2 ( 1x JN 1x for staff in outreach
areas)
IT/IM including computers/ printers/ software
Purchase colour printer $ 6,500
Computer Upgrades x 2 $ 6,000
Printer Upgrades x 2 $ 3,000
IT/IM computer services support -SWHC
Rent – South West Healthcare
Vehicles- Lease, Petrol, rego, repairs, tyres, insurance
Postage, Couriers
Advertising
Jh/reports/community health plan 03
$ 5,950
$15.500
$ 3,168
$13,173
$21,757
$ 1,600
$ 1,500
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Membership Fees;
Books, Journals
Accounting Fees –South West Healthcare
Catering , Linen, Domestic supplies
Replace/Add Equipment
Travel and accommodation
Journalist Fee to investigate with agencies, write and place
articles in local newspapers
$40 @ 3 hours per week
Continuing Education Fees
Printing, Stationery & Photocopy
TOTAL:
4.0
$ 890
$ 1,100
$ 6,000
$ 6,500
$ 2,000
$ 8,700
$ 6,240
$ 6,258
$ 5,900
$106,236
PCP- South West Strategy Specific Budgets
PCP – South West Review of governance, role and
function
Salary and Wages
Consultancy fee
Venue hire & hospitality – 4 meetings
TOTAL
Healthy Communities Strategy
Salary and Wages
2002-03 contribution paid to Healthy Communities Project
– ( requested to be paid in 2003/04 year)
Dentist recruitment strategy – exam fee
Dental recruitment strategy – Dental Board Registration
TOTAL
Jh/reports/community health plan 03
$ 5,843
$ 20,000
$1,040
$ 26,883
$ 9,623
$ 24,500
$ 690
$ 4,000
$ 38,813
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2003 / 2004 COMMUNITY HEALTH PLAN
Vascular Disease Strategy
Salary and Wages
External Evaluation
Staff training – GP’s x1 Allied Health x1 & Aboriginal
Health Workers x2
Diabetes Education Materials for Aboriginal Health
workers and
indigenous people (40 x glucometers ; finger pricks; strips;
swabs;
Walking Shoes 5 @ $120
Pedometres 15 @ $25
Food & Nutrition Education Sessions 8 @ $120
External staff hire eg dietitians/ podiatrists/ pharmacists /
GP /
@ average of $ 55 per hour 10 hours
Purchase of indigenous specific diabetes education
brochures
$60 @ 15
Diabetic Retinopathy Screening – film $7 per person @ 120
Steering Group venue hire and hospitality 8 @ $175
2002-2003 Integrated Health Promotion Project - National
Heart Foundation Project, project commenced
2002 – 2003 Integrated Health Promotion Project – Heart
Research Centre Vascular disease training and GP
dinner/education , July 18th/19th
TOTAL
Jh/reports/community health plan 03
$140,131
$ 4,500
$1,950
$ 8,000
$ 600
$ 375
$ 960
$ 5,500
$ 900
$800
$1,400
$56,808
$ 13,500
$235,424
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Service Co-ordination Regional Strategy
Salary and Wages
SWARH Fee
Contribution to SWAN for Service Directory Update
Flexible Funding Pool for agency support in Service Co-ordination
reform as per regional guidelines
All initiatives to be endorsed by the Regional Service Co-ordination
Working party and PCP South West Management Team
TOTAL
Access to Information About Services – Consumer Project
Salary and Wages
Consumer sitting fees & travel reimbursement
17 consumers X 12 meetings X 2.5 hours X $20 per hour
Travel @ 10 consumers @ $15 X 21 meetings
Service Provider Training for “ information hubs”
3 sessions for 15 service providers
Computer & Printer for 3 information hubs
TOTAL
Footholds on Safety*
Salary & Wages for PCP staff to participate in Lyndoch
Project
TOTAL
$ 89,300
$ 15,000
$ 7,000
$ 75,000
$ 186,300
$54,490
$10,200
$3,150
$ 1,200
$ 12,500
$81,540
$ 5,843
$ 5,843
* This project is auspiced by Lyndoch
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Domestic Violence
Salary and Wages
$10,668
Oral Health
Salary & Wages
$ 5,844
2003-2004 Integrated Health Promotion
Depression, social isolat. lack of quality support in people with
vascular disease (CVD, stroke, diabetes)
Salary and Wages – PCP Staff
Salary, wages and consumables, participating agencies and
consumer pilot
TOTAL
2003-2004 Integrated Health Promotion
Eat Well Be Active
Salary & Wages to prepare submission and for first year of project
development
PCP contribution to submission
TOTAL
Jh/reports/community health plan 03
$ 38,577
$ 47,146
$ 85,723
$ 29,926
$ 10,000
$ 39,926
Page 64 of 67
APPENDIX 1 PRIORITIES FOR ACTION TEMPLATE



Has the PCP identified and explained the rationale for their priorities?
Are the priorities based on the comparison of the community profile with the service profile,
indicating the major issues and service gaps within the catchment?
Have the priorities been revised from the previous Community Health Plan in cases where:

Do the priorities include integrated health promotion and service coordination initiatives?
 There are new emerging issues;
 Priorities have changed (e.g. due to new data or input from sonsumers and carers); or
 The previous plan’s analysis of priorities, gaps and emerging issues needed further work?

3.
Do the priorities include integrated health promotion and service co ordination initiatives?
STRATEGIES
Each Strategy should contain all the elements described below (problem definition, solution
generation, support and resources, and review and evaluation).
Problem Definition




What population groups / health and well-being issues are being addressed?
Is the problem definition based on the analysis in the Community and Service Profile?
Are the goals (desired changes in health and well being for the targeted population group/s) clear,
appropriate and manageable?
Are the Objectives (changes in consumers’ experience of services and programs or changes in risk
and protective factors) clear, appropriate and manageable?
Solution Generation:
(Changes in practices, processes, protocols and systems, designed to meet the objectives).





Are the solutions linked to the stated goals and objectives?
Are evidence based practice and good practice models used?
Is relevant statewide action identified?
Is an appropriate mix of interventions identified?
Are the activities required identified?
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Support and Resources:




Are the roles and responsibilities of the key stakeholders, including who will implement and
monitor each activity identified?
Are appropriate resources allocated (including estimated budget for health promotion)?
Are key capacity building strategies (including workforce development) identified?
Are proposed timelines for each activity identified?
Review and Evaluation:
(See also the Impact Evaluation Guide and Maps of Program Logic on the PHKB:
http://hnb.dhs.vic.gov.au/rrhacs/phkb/phkb.nsf)



Is there a Plan for Review and Evaluation?
Does it evaluate: process (reach), impact and outcome?
Is it clear how will success be measured?
Overall Comments:




Is strategy forward looking, building on achievements and strategies to date?
Does the strategy integrate the key deliverables of integrated health promotion and service
coordination initiatives?
Are targeted population groups included in the development and implementation of the strategy?
How adequately does the strategy contain the components outlined above?
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Appendix 2 : Integrated Health Promotion Program Summary Grid
Program Goal: (As determined in Problem Definition Section 2.3 above)
Population Target Group/s: (As determined in Problem Definition Section 2.3 above)
Program
Objectives
Health Promotion
Interventions & Capacity Building strategies9
Objective 1:
Screening, individual risk assessment and immunisation
Estimated Impacts10
(Qualitative &/or Quantitative)
Social marketing /Health information
Health education and skill development
Community action
Settings and Supportive Environments
Organisational Development
Workforce Development
Resources
Total Budget per Objective
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Estimated11
Reach
Timelines
& by which
agency12