Name of PCP
Case Study Title
Which PCP Program
Logic domain does
your case study
relate to?
What was the need?
Central West Gippsland Primary Care Partnership
Development of Latrobe Cluster E-Support Planning Protocol
Early Intervention and integrated care
The Latrobe local government area is situated in the centre of Gippsland,
Victoria, and encompasses four major towns and several outer lying
townships covering over 1400km2, with a population of approximately
74,000 people.
Local community services are spread between the four major towns
which poses geographic (and consequently time and financial)
constraints for service coordination and case conferencing between
health and welfare professionals and their clients.
Consultation with local health services revealed the need to improve
communication between services to reduce duplication of processes,
enhance timeliness of access to services, and enhance outcomes for
people requiring multiple services.
Utilising the regions’ current electronic referral platform (S2S) for the
creation of shared e-support plans was identified as an effective way of
addressing this need.
To support this system, a protocol was developed to provide a generic
framework for interagency support planning.
Agreed referral pathways, tools and communication processes were
documented to reduce unnecessary duplication and ensure that
assessments and services are coordinated around individual need and
build on individual and carer strengths.
What was the aim of
the initiative/action?
The protocol is underpinned by the principles of Service Coordination and
person centred practice, and enhanced by the implementation of the
Wellness and Re-ablement/Active Service Model
The aim of this initiative was to maximise wellbeing outcomes and goal
attainment for individuals with complex needs who require multiple
service / agency involvement:
 through enhancing communication and service coordination
between services,
 by outlining an agreed process for shared e-support planning in
Latrobe City municipality.
The objectives were to:
 ensure that people receive the right assessment and service at
the right time,
 minimise the number of times people have to tell their stories,
 reduce waiting times for services by using resources as efficiently
as possible, and
 provide a communication tool for services and staff involved in
an individuals’ care.
Who was the target
group?
People who;
 reside in the Latrobe LGA
 have identified a goal that requires involvement of two or more
of the participating services including the service initiating the
Plan, and
 who need inter-service/agency coordination and communication
to support effective outcomes and
 have a chronic health condition and/ or
 need episodic complex care
Please see the vignette at the end of this document for information on
how this project improved an individuals’ journey.
What was the setting Health and Human services in the Latrobe Valley
Who did you work
with?
The Key Stakeholders for this project are:
 Latrobe City Council
o HACC Assessment Service
o Home and Community Care Program
 Latrobe Community Health Service
o Primary Intervention Services (allied health)
o Ambulatory Care
o Commonwealth Respite and Carer Programs
o Home Care Packages
o Disability Support Services
 Latrobe Regional Hospital
o Community Rehabilitation Service
o Sub acute Ambulatory Care (SAC)
o Hospital Admission Risk Program (HARP)
o Post Acute Care (PAC)
o Transition Care Program
 Villa Maria
o Home Care Package provider
 Southern Cross Community Care
o Home Care Package provider
 Gippsland Multicultural Service
 Quantum Support Service
How did you do it?
An e-care planning working group was formed with key stakeholders.
Regular meetings were facilitated to discuss the following:
 The electronic platform for e-care planning – S2S support plan
 The development of a formal agreement and protocol for the use
of e-care planning in the region
 Staff training requirements
 Resourcing and support to assist services to implement the
system within their service
A draft agreement was formed, in-person training was conducted with
participating services, and a trial phase was implemented between June
and December 2014.
In September 2014 the CWGPCP team created online training for the ecare planning system on S2S. These modules mean that e-care planning
training is available to participating staff at any time.
What was achieved?
(Consider whether
results were benefits
for clients and/or for
service providers
and/or for the
system)
Following the trial period, meetings were held to review and revise the
protocol so that it reflected the actual practice of the e-care plan system
and the expectations of each participating service.
Since the commencement of the use of the e-care system by clinicians in
2014, 184 e-care plans have been developed between healthcare
providers in the Latrobe and Baw Baw region.
Clinicians report that e-care plans have increased (and subsequently
improved) effective communication between services which has resulted
in flow-on benefits for the person receiving services.
Increased understanding of individuals’ therapeutic goals and service
delivery have ensured better follow-up between healthcare visits by
other care-plan participants (i.e. clinicians). For the person receiving
services, this follow-up serves as a reminder and accountability
mechanism to self-manage the health goals they chose and agreed to
when the care plan was developed, and thus, better health outcomes in a
shorter period of time.
The implementation of e-care plans in Latrobe has provided clinicians
with an easy-to-use communication platform that broadens clinician’s
capacity to provide a better, coordinated healthcare service, and
strengthens the individuals’ experience of person centred care. Increased
communication between services has ensured individuals’ with complex
conditions do not have to recount or explain their visits between
healthcare providers.
E-care planning enables participants to coordinate communication across
a large geographical area. Clinicians can provide input at a time and place
that is convenient to them, thus improving efficiency and cost to the
healthcare service.
What is the status
and sustainability?
The revised protocol has been sent to the CEO’s of the participating
services to be signed. The signed protocol will be sent to all participating
services for further distribution and communication with all workers who
use the system.
Signatories to this protocol will work to ensure sustainability of this
partnership and coordinated care pathways and processes. Key roles will
include supporting the ongoing partnership between services, strategic
management, development and oversight of systems and tools,
clarification of roles and processes, communication, and resolving any
issues that arise between services.
The e-care planning modules on the CWGPCP website will continue to be
an available resource for staff who require it.
What was the
specific role of the
PCP?
CWGPCP facilitated collaboration between the members through
coordinating working group meetings and facilitating discussions
between participants about the proposed use of the e-care planning
system. CWGPCP developed the initial protocol (in collaboration and
consultation with partners), developed processes and procedures,
provided training to staff groups, and facilitated the review and
development of the final protocol document.
What lessons have
you learnt?
Services that had a sound understanding of goal directed care planning
and completed care plans for the people who access their service
appeared better placed to trial the electronic system.
Services that had clear commitment of upper management to support ecare planning protocol development and implementation of the system
were more engaged, accepting and cooperative throughout the process.
These services also produced more e-care plans during the trial period
and reported the greatest benefits for the people accessing their
services.
The commitment of services orientated toward aged care fluctuated at
times due to the larger scale reforms within this sector, and uncertainty
regarding the timelines for implementation of “My Aged Care” and
functionality of this system to record care plans.
PCP Contact Person
Position/Title
Client Vignette
Liz Meggetto
Executive Officer, CWGPCP