Enduring Strategy 4 – Person-centred, equitable, seamless access

Moving routine, non-urgent and less complex specialist outpatient services out of hospital settings in partnership with primary care

Priorities for 2023

• Pilot a model for primary care access to specialist advice. The Department of Health is developing and testing an approach to increase primary care access to specialist advice with the aim of keeping patients supported in primary care, where clinically appropriate. This initiative includes developing a clinical model and identifying the workforce and technology required to deliver this model.
• Design and build Smart Referrals WA, an electronic solution that will transform WA Health’s management of referrals. The system will automate multiple parts of the referral process and give referrers greater ability to track and manage referrals.
• Ongoing development of referral access criteria for the WA Health public outpatient system. Referral Access Criteria (RAC) will provide clear and consistent guidance about which patients are appropriate for referral to public specialist outpatient clinics and what information and diagnostics are required to support accurate processing and prioritisation of referrals.
• Review of the WA Health Specialist Outpatient Services Access Mandatory Policy, in consultation with stakeholders. Updates are expected to guide greater consistency of the patient experience and enhance linkages with primary care.

Achievements to date

• Since the first WA health system Referral Access Criteria (RAC) for Urology was implemented in 2021, RACs have been implemented for Neurology, Ear, nose and throat (adult and paediatric),Direct access gastrointestinal endoscopy, and Ophthalmology. Each RAC reflects agreement among all health service providers (HSPs) on what is clinically appropriate to refer to a specialist outpatient service and provides referrers with guidance on the referral information required to inform timely, accurate clinical triage and patient preparedness for initial appointment.

Requiring all metropolitan Health Service Providers to progressively provide telehealth consultations for 65 per cent of outpatient services for country patients by July 2022

Priorities for 2023

• Conduct a system-wide outpatient digital blueprint to prioritise improvement initiatives. The blueprint will map the current state, end-to-end outpatient process, from referral to discharge, across the system, and identify the highest priority opportunities for streamlining both processes and technology. This includes opportunities to improve telehealth and broader virtual care, such as remote monitoring and wearable devices. 
• Develop a virtual care strategy and roadmap. Building on the findings of the digital blueprint, this project will produce a strategic approach to virtual care in outpatient settings, including sustained uptake of telehealth.
• Complete a videoconferencing needs assessment. This will involve analysis of available videoconferencing system options in order to identify a preferred, long-term solution for the WA health system. 
• Refine the WA health system Virtual Care dashboard, which provides WA health system staff with a concise, reliable and timely picture of virtual care options (including telehealth) across the State.

Achievements to date

• Significant increase in the number and proportion of telehealth appointments across the WA health system compared to baseline (pre-COVID) levels.
• Manage My Care, the WA health system’s first patient-facing app and web portal, was rolled out in all metropolitan and regional areas in 2022. Manage My Care (MMC) enables patients and carers to view their WA Health public outpatient appointments and referrals, including telehealth appointments, and allows users to digitally track and manage their outpatient care at a time convenient to them. At April 2023, more than 93,000 patients had linked to accounts, and the app service has been logged into more than 2.4 million times. Manage My Care been used more than 9,000 time to reschedule an appointment and 13,000 times to update patient details. Referrals information has been viewed 830,000 times and appointment information 880,000 times.

Develop and implement a systemwide approach to identifying and supporting people who are frequent users of health services including emergency and outpatient services to improve pathways of care and reduce presentations.

Priorities for 2023

• Review existing community and ambulatory services, provide an evidence-based Community Services Strategy for investment in future community services, clearly identify alternatives to hospital-based care and reduce the need to direct patients to admitted pathways. Increase transparency of existing hospital alternatives to address the challenges faced by staff and patients in navigating the system.

• Develop a service model, funding structure, and business case for improved accessibility and provision of a Community Cardiac and Pulmonary Rehabilitation Model of Care, and develop a replicable model/process that can be expanded across other community-based models of care required by high-frequency presenters to hospital
• Develop a service model, funding structure, and business case for improved access to specialist advice by primary care providers at the point of referral to the outpatient, community or acute care settings., reduce emergency department referrals and specialist outpatient referrals of patients who could be better managed in the community/primary care setting and improve links and access to the hospital for primary care providers.
• Develop a draft model of service delivery and Hospital in the Home (HiTH)  feasibility assessment as part of a broader remit to expand the range of hospital substitution programs, HiTH and technology-assisted independent living solutions to increase the number of people who receive acute care at home, commencing with respiratory patients.

Achievements to date

• Completed a comprehensive discovery phase from 2020–2022 to understand patient, clinician and carer experiences of chronic obstructive pulmonary disease (COPD) and cystic fibrosis (CF), underlying causes of frequent hospital presentations and models of care intended to reduce hospital use. The nine activities of the discovery phase were:
  • Clinician and consumer survey
  • Discussions held with consumer and carers
  • Initiative scanning
  • Quantitative data analysis
  • Literature review
  • COPD and CHF symposium
  • Innovation workshops
  • Service analysis
  • Information sharing
• Delivered a Multiple Admission Report that aims to identify patients who have had multiple unplanned admissions to hospitals in metropolitan Perth in the last 365 days, in real time.
• Delivered the Whole Person Model of Care.
• Using $4.4 million in State Government support, continue to provide medical care and support for the homeless in Perth, following the pilot of WA’s first Medical Respite Centre, managed by East Metropolitan Health 

Improve access to health assessment and treatment in the community for people with chronic conditions, such as chronic heart failure, diabetes, and chronic obstructive pulmonary disease and mental health by fostering models that deliver care closer to home.

Priorities for 2023

• Building on the joint work and collaboration established between the WA Primary Health Alliance (WAPHA) and WA’s five direct care Health Service Providers (HSPs) through the HSP Protocols (in place from 2020 -2023). The focus of this collaboration for 2023-24 will be a scope of work based on shared system priorities, underpinned by data sharing, that improves referral pathways and integrated models of care between the primary and acute sectors that delivers care in the most appropriate and accessible way.
• WAPHA continues to partner with HSPs to improve care in the community for people with chronic conditions under the direction of the National Health Reform Agenda and the Strengthening Medicare Taskforce Review recommendations.

Achievements to date

• Working foundations and operational relationships have been built and sustained, enabling joint work and operational collaboration.
• The integrated supported discharge and community support program for inpatients presenting with an exacerbation of chronic obstructive pulmonary disease (COPD) has been rolled out across all metropolitan HSPs, in collaboration with community-service providers, Silverchain and Asthma WA. These programs are commissioned by WAPHA to 30 June 2025.
• Integrated diabetes service development in WA Country Health Service (WACHS) areas better supports those diagnosed with diabetes in regional and rural areas.
• Partnership through the multi-agency Peel Mental Health Taskforce to improve the coordination of mental health care for young people in the Peel region.
• Joint aged care case conferencing is supporting more collaborative assessment, support and treatment for those accessing aged care services.

Regional communities face unique challenges in accessing health care. Investing in innovative models of healthcare, including collaborative care, provides an opportunity to support rural and regional healthcare providers to provide patients with the care they need.

Priorities for 2023

• An Equity of Access to Care for Country Communities Policy, being drafted by the Department of Health in collaboration with the WA Country Health Service (WACHS), includes patient flows as an appendix.
• The Mental Health Emergency Telehealth Service (MH ETS) (external site), which provides specialist mental health care to people who attend 91 regional hospitals, nursing posts and Aboriginal Medical Services with acute mental health, drug and alcohol conditions, is collaborating with the WACHS mental health team to provide an aftercare service for children and adolescents who presented to regional Emergency Departments.           

Achievements to date

• The Maternity and Obstetrics Emergency Telehealth Service (external site) is an acute specialist telehealth service, launched in 2022, to assist pregnant women presenting to WACHS Emergency Departments by supporting midwives working in regional WA with advice, patient assessment and digitally enabled remote monitoring of women in labour Since it commenced, the service has received over 1400 referrals and assisted with 11 emergency deliveries.   
• The Acute Patient Transfer Coordination (APTC) service (external site), led by WACHS in partnership with regional health providers, the Royal Flying Doctor Service and St John Ambulance, oversees safe, timely and efficient patient transport to and from regional and metropolitan hospitals for admitted country patients. The service recently celebrated one year of operation with more than 15,000 patient transfers, expansion to a 24/7 service, and WA’s first co-located collaboration between three leading regional health providers.
• The Mental Health Emergency Telehealth Service (external site) part of the WACHS Command Centre, provides country doctors and nurses with access to specialist mental health nurses and psychiatrists via video conference to assist in caring for people who present to 91 regional hospitals nursing posts and Aboriginal Medical Services with acute mental health, drug and alcohol conditions. The service has resulted in more than 87 per cent of presentations avoiding the need to be transferred to another hospital for care.
• Through the Palliative Care Afterhours Telehealth Service (external site)regional patients presenting to their local Emergency Department have access to specialist palliative care nurses, outside the business hours of local services.  

Priorities for 2023

• Develop Western Australia’s position for National Aged Care Reform
• Diversify Transition Care Program and pilot with Aboriginal Medical Services
• Implementation of health priorities within the WA Seniors Strategy
• Supporting work with the WA Ministerial Advisory Panel on Aged Care
• Develop and implement a Residential Respite Pilot for patients transitioning from hospital to residential care facilities.

Key achievements to date

• In a national first, the WA Government has partnered with Aboriginal Community Controlled Health Organisations (ACCHOs) to pilot culturally   responsive, short-term community-based care to support older Aboriginal Western Australians (50 years and older) leaving hospital. This has led to integrated care for Aboriginal people, close to home. 
  • Aboriginal people are underrepresented in the Transition Care Program (TCP) across each state and territory of Australia. Nationally, there is no TCP specifically designed for Aboriginal people and a need to improve the cultural responsiveness of service delivery.
  • Broome Regional Aboriginal Medical Service (BRAMS), South West Aboriginal Medical Service (SWAMS) and Geraldton Regional Aboriginal Medical Service (GRAMS) are the first ACCHOs to deliver culturally appropriate transition care for Aboriginal people.
  • The pilot has resulted in a 15-fold increase in the number of Aboriginal people accessing TCPs in pilot regions, leading to better outcomes for Aboriginal people and minimising unnecessary extended hospital stays and re-admissions, freeing up hospital beds for those who need care.
• The Department of Health led a Transition to Care contract review and design process, including pricing and performance frameworks that will support more contemporary transition care services that better meet demand, including a better mix and distribution of places. Under the TCP, the procurement process for these services is progressing.
• The WA Ministerial Advisory Panel on Aged Care (MAPAC) was established in July 2022 to provide expert, balanced and timely advice to the Minister for Health about health and related care issues affecting older Western Australians and service providers. Reporting to the Parliamentary Secretary for Health, the panel comprises leaders from 7 major aged care providers, Aged and Community Care Providers Australia, the United Workers Union and the Department of Health.

The work of the Ministerial Advisory Panel on Aged Care led to the development of a Vacant Bed Portal to help older people leave hospital as soon as they’re medically fit by quickly locating an appropriate residential care vacancy to which they could be discharged.

• The Department of Health worked with the Department of Communities to develop the first State Seniors’ Strategy (2023–33). The Department of Health will manage implementation of three actions in the State Seniors’ Strategy (2023–33) Action Plan (2023–27), including continuing to scope and implement models of care to support independence at home and other appropriate settings.
• The WA Government has partnered with the Australian Government and aged care service providers on a Residential Respite Pilot to provide access for patients to an extended period of respite care as a transition from hospital to a residential aged care facility. The pilot aims to use existing capacity in the sector and better support patients on the pathway to residential care.

Priorities for 2023

• Partner with the National Disability Insurance Agency (NDIA) and aged care sector to adopt a person-centred approach (rather than a provider-centred approach) to manage complex care, including navigation and joint case planning, via the NDIS long stay audit.
• Agreements between the NDIA and mainstream services in WA, coordinated by the Department of the Premier and Cabinet, to facilitate effective patient and carer linkages.
• Continue From Hospital to Home disability transition care pilot to support people with more complex health needs.
• Continue Transition Care pilots to build a more contemporary model.

Key achievements to date

• The Department of Health has met the needs of people with disability and complex needs and improved the coordination of care by driving cross-agency bespoke solutions and establishing second and third From Hospital to Home (FH2H) disability support transition pilots for people with disability and complex needs. The result is the provision of care to people in the most appropriate setting.
• The Department also provided extensive systemwide feedback about hospital discharge processes and continues to advocate to the Australian Government for operational refinements to the National Disability Insurance Agency (NDIA) via Health Minister's Meetings and Disability Reform Ministers Meetings. The result has been improved discharge planning process for people with disability.
• To reduce the number of people waiting to access aged care services, the Long Stay Working Group has consulted on more than 750 patients experiencing discharge delay. This included the approval of interim funding packages (with a total value of more than $1.02 million) for 58 individuals to provide interim solutions that enabled discharge to community living.
• The third From Hospital to Home pilot was launched in February 2023 in Swan View to support two people with more complex mental health and psychosocial needs. Coolbinia and Swan View pilots have supported the discharge of 14 patients, reducing the bed block burden by 1337 days.
• To transition long stay patients from WA hospitals to appropriate care settings, the Department of Health led a review of the contract and design process of the Transition Care Program (TCP) to support more contemporary transition care services that better meet demand and distribution of places. The procurement process for these TCP services is in progress.
• The Ready to Go Home project aimed to improve the hospital experience of people with disability and reduce barriers that contribute to discharge delays, was finalised on 30 March 2023.
  
  The National Disability Services (NDS) and Department of Health WA project was funded by the Australian Government.
  
  Ready to go Home resources were co-designed and co-developed with health consumers with disability, disability service providers and health professionals. Service provider resources were aimed at disability services and mental health organisations, and Health professional resources for clinicians and Hospital Service Providers
  
  All clinician resources were uploaded on the WA health system intranet for easy accessibility and the NDS (external site) has published most resources created by the project on its website.  

• TCPs aim to increase interim options for older Western Australians leaving hospital. These include:
  • reforming and expanding the long-standing aged care TCP procurement process, to start July 2023.
  • The launch on 15 May 2023 of the Residential Respite Pilot program to transition older patients to respite beds while awaiting residential aged care placement.
• Bed availability data and better matching, through:
  • Partnership with the Aged Care and Community Providers Association and development of a real time data portal on bed vacancies in residential aged care facilities.
  • A centralised coordination referral function (‘Aged Care Hub’) established to oversee referrals to State-subsidised aged care programs.
  • Supporting Health Service Providers with bespoke solutions for older patients with complex needs, including working across agencies and levels of Government to ‘unblock’ barriers to discharge.