Although the Northern Sydney Collaborative Commissioning initiative is still officially in the development phase, they have already commenced delivering improved services for frail and older people in their area.
The partnership between Sydney North Health Network (SNHN) and Northern Sydney Local Health District (NSLHD) is focused on improving rapid care for frail and older people in Northern Sydney. It aims to respond to the needs of frail and older people with more proactive, timely and connected support that is tailored to each person's needs and gives choice with where care is provided.
While there are a range of features planned to deliver this vision, the partnership have already commenced two services to enhance GP-led management in the community:
Geriatrician Outreach to Primary Care has commenced across Northern Sydney and aims to increase Geriatrician input into GP‑led patient planning and care in the community earlier than would otherwise occur, while building relationships and facilitating two‑way learning opportunities. It seeks to work collaboratively with GPs to manage complex patients and those that may be at risk of deterioration.
NSLHD Geriatricians are now proactively engaging GPs to introduce this model via practice visits, phone and email. The Geriatricians are using NSLHD ED data to focus their support to local GPs that have a higher volume of patients presenting to ED or patients that are coming into ED frequently.
Over the past 10 weeks the Geriatricians have provided 129 engagements with GPs across Northern Sydney, with 52% of these in‑person visits and 44% over the phone. The service has been well received by local GPs and the figures below provide some early insights into the types of issues and the risk profile of the patients being discussed by the GPs and Geriatricians.
The Concierge Service is a telephone/online support service commissioned by the partnership earlier this year. A key feature of the commissioning process was commissioning a provider based on experience and capability and then codesigning the service with the provider once engaged.
The Concierge Service (branded as 'Health Navigators') currently provides support for health care professionals in Northern Sydney to navigate, troubleshoot and coordinate community‑based primary health, aged and social care and some hospital‑based services for elderly, frail and vulnerable people within their care.
The service is now active for local healthcare providers (with support direct to consumers planned for the future) and has received 35 referrals for support to date. Early insights from these referrals include:
