Capital Health Network ACT PHN Baseline Needs Assessment 2016 About Capital Health Network Capital Health Network (CHN) is ACT’s Primary Health Network. We play a pivotal role in supporting general practice, primary, aged care and community care services to better meet the health needs of the community. Acknowledgements CHN wishes to acknowledge and thank everyone who provided valuable input to this assessment and made this report possible. CHN also acknowledges that Canberra has been built on the land of the Ngunnawal people. We pay our respects to the Elders of the land both past and present and to their continual relation to their ancestral lands. We celebrate Aboriginal and Torres Strait Islander cultures and their ongoing contributions to the ACT community. Suggested citation Capital Health Network 2016. Baseline Needs Assessment 2016. Canberra: Capital Health Network. Contact details Any enquires about or comments on this publication should be directed to: [email protected] 02 6287 8099 Capital Health Network PO Box 9, Deakin West ACT 2600 https://www.chnact.org.au/ i Contents List of tables ......................................................................................................................................... viii List of figures .......................................................................................................................................... ix List of abbreviations .............................................................................................................................. xii Preamble .............................................................................................................................................. xiii Executive Summary ...............................................................................................................................xiv 1. Whole of System Issues .................................................................................................................. 1 Overview ............................................................................................................................................. 1 Transition of care ............................................................................................................................ 1 Key Issues ............................................................................................................................................ 2 Communication breakdown at the public/private health care interface ....................................... 2 Priority Issues ...................................................................................................................................... 3 Lack of consistency in discharge planning processes ..................................................................... 3 Variable access to outpatient services ............................................................................................ 8 Lack of knowledge and awareness of support services ................................................................ 13 Poor information infrastructure to support shared care planning and transition of care ........... 13 Potentially preventable hospitalisations ...................................................................................... 19 2. Chronic Disease ............................................................................................................................. 25 Overview ........................................................................................................................................... 25 Prevalence of chronic disease ....................................................................................................... 26 Risk factors .................................................................................................................................... 30 The Burden of Disease .................................................................................................................. 31 Key Issues .......................................................................................................................................... 32 Whole of system approach to chronic disease prevention and management ............................. 32 Activated consumers ..................................................................................................................... 36 Early identification, assessment and intervention for patients at risk of poor health outcomes 39 Health assessment and screening ................................................................................................. 44 Comprehensive shared and coordinated care to patients with complex and chronic conditions ...................................................................................................................................................... 47 Care coordination ......................................................................................................................... 50 Medication management .............................................................................................................. 53 3. Workforce ..................................................................................................................................... 56 Overview ........................................................................................................................................... 56 ii Workforce statistics ...................................................................................................................... 57 GPs ................................................................................................................................................ 59 Practice Nurses ............................................................................................................................. 59 Key Issues .......................................................................................................................................... 59 Workforce sustainability ............................................................................................................... 59 Priority Issues .................................................................................................................................... 60 High performing primary health care ........................................................................................... 60 New and emerging workforces ..................................................................................................... 62 Clinical training and clinical placements for health professionals ................................................ 62 Aboriginal and Torres Strait Islander workforce ........................................................................... 63 Collaboration within the current workforce ................................................................................. 64 Leadership and change management ........................................................................................... 65 Team working................................................................................................................................ 66 4. Aboriginal and Torres Strait Islander Health ................................................................................. 67 Overview ........................................................................................................................................... 67 Key Issues .......................................................................................................................................... 70 Pre and post natal healthy lifestyle support for mothers ............................................................. 71 Crystal methamphetamine use among Aboriginal and Torres Strait Islander youth ................... 72 Children and youth........................................................................................................................ 73 Priority Issues .................................................................................................................................... 74 Smoking during pregnancy ........................................................................................................... 74 Social, emotional and cultural wellbeing ...................................................................................... 75 Access to services .......................................................................................................................... 78 Need for an integration of early childhood services ..................................................................... 81 Chronic disease management ....................................................................................................... 82 5. Vulnerable populations ................................................................................................................. 85 Overview ........................................................................................................................................... 85 People from culturally and linguistically diverse (CALD) backgrounds ............................................. 85 Key Issues .......................................................................................................................................... 87 Barriers to interpreter use ...........................................................................................................