Chronic Disease and Post-Acute Care

Chronic diseases are the leading cause of illness, disability and death in Australia.  With changing lifestyles and ageing population, chronic diseases have become increasingly common and now cause most of the burden of ill health.

Based on available data, the table below indicates some of the key priority areas in the South Eastern Melbourne catchment.  This includes prevalent chronic diseases in the region, identified local government areas with higher-than-average chronic disease rates, and ‘at risk’ population groups.

At risk areas

Place-basedDiagnosisVulnerable groups

Frankston
Dandenong
Casey
Cardinia

Iron deficiency
COPD/asthma
Heart Disease
Musculoskeletal conditions
Kidney disease
Cancer
Diabetes
Dementia

Refugees
Homeless
CALD
Elderly (in Residential Aged Care Facilities)
ATSI


Commissioning approach

In order to commission chronic disease services that meet the needs of the catchment, SEMPHN will work with the sector to co-design models of care that have the potential to reduce potentially preventable hospitalisations and support the management of people with chronic conditions in a primary care setting. This will result in better health outcomes for patients, including models of care that have a focus on:

  • Self-management
  • Care coordination and continuity of care
  • Service integration between primary, secondary and tertiary/acute services
  • Post-acute care (i.e. discharge planning)

SEMPHN continues to engage with a range of stakeholders across the sector to support this approach and encourage innovation and partnerships to address chronic disease in our community.

You can register your interest for funding opportunities. You will receive updates about the tender process, including guidelines and timelines, when available.

See more information about chronic disease for General Practice and health professionals.


Information session for General Practice: building capacity to support care coordination for chronic and complex conditions.

On 12 April 2017 in Doveton, a tender information session was held that covered an overview of the grants on offer, an outline of the application process, including response expectations, and an opportunity for questions and answers.

A recording of the session can be viewed here. The slides can be viewed here.

A recording of the question and answer section of the session can be viewed here.

A question and answer document from the session can be found on Tenderlink.

A sample budget can be viewed here. It can be used as a guide to help practices establish their own budget as part of the application. The total budget requested should be included in the final (free text) question.  

The closing date for requests for further information via the Tenderlink forum, is 20 April, 2017.


Commissioning opportunities awarded

Building capacity to support care coordination for chronic and complex conditions

A total of $3 million in grants has been awarded to 34 general practices across the 10 local government areas in the South Eastern Melbourne PHN catchment. 

The successful practices are:

General PracticeLGA

Airlie Womens Clinic Pty Ltd (Prahran)

Stonnington

Emerald Medical Centre Pty Ltd Cardinia
Sonic Clinical Services Pty Ltd Port Phillip
Atticus Health Pty Ltd Frankston
Southland Medical Centre Kingston
First Health Medical Centre Casey
Junin Pty Ltd ATF The Langpark Medical Centre Frankston
GPR Australia Pty Ltd Mornington Peninsula
Distinct Health Care Clinic Greater Dandenong
The Salvation Army Port Phillip
Boldly Going Pty Ltd & S. P. Kaye & K. S. Reid & others T/as D&C Partners Kingston
Eastbound Clinic Glen Eira
Springvale South Medical Centre Kingston
headspace Frankston (YSAS Pty Ltd) Frankston
The Trustee for Health and Education Trust Glen Eira
Thompson Road Clinic Casey
S.E Mc Donald Cardinia
MyClinic Elsternwick Glen Eira
First Health Medical Centre (Casey) GP Pty Ltd Casey
Healy Lazarovits Prichard & Taft Partnership Stonnington
Pakenham Family Health Cardinia
Total Care Medical Group Frankston
MyClinic Balclava Port Phillip
St Kilda Medical Group Port Phillip
Peninsula Holistic GP Mornington Peninsula
Cabrini Health Limited Glen Eira
Becmor Pty Ltd - T/A Amberly Healthcare Casey
MyClinic Prahran Stonnington
Langmore Clinic Casey
Sri Bros Pty Ltd Kingston
Doctors@Bayside Bayside
AVMC Holdings Pty Ltd ATF Alma Village Medical Centre Unit Trust Glen Eira
Link Health and Community Bayside, Monash
MPGn&J PEREIRA PTY LTD Greater Dandenong

The grants will build each practice’s capacity to manage patients with chronic and complex conditions and help reduce potentially preventable hospitalisations – one of the key PHN national priorities.

System-wide change is expected to result from the grant-funded activities which will run from June 2017 to June 2018. Specifically, the objectives are to:

  • improve the health system, service and health literacy of patients and their families
  • enhance patients’ ability to manage their own health needs through self-care strategies
  • improve health outcomes for those patients with poorly managed chronic conditions
  • reduce the rate of potentially preventable hospitalisations for chronic conditions in the SEMPHN region
  • increase the efficacy of care coordination strategies to better manage chronic and complex conditions and to improve the patient’s quality of life, and
  • improve the sustainability of the practice by improving systems and quality to accommodate more clients and offer additional billable services.

The Commissioning Process

An open tender process was used for the commissioning of services to build capacity to support care coordination for chronic and complex conditions. 

Applicants who registered via Tenderlink were invited to apply by responding to a series of questions, which were assessed against a set evaluation criteria by an assessment panel. The panel reached consensus in relation to the successful applications.


Improving health outcomes for priority populations groups with complex and chronic conditions

In April 2017, eight health care providers received funding to deliver a suite of initiatives to improve health outcomes for priority population groups with complex and chronic conditions within the South Eastern Melbourne PHN region. The successful applicants are: 

ProviderPriority focus groups

The First Step Program in St Kilda 

  • Culturally and Linguistically Diverse (CALD)
  • Homelessness
  • Refugees and Asylum Seekers
Mackie Road Clinic in East Bentleigh 
  • Over 65yo
  • Culturally and Linguistically Diverse (CALD)
Connect Health and Community (formally Bentleigh Bayside Community Health)
  • Over 65yo
  • Culturally and Linguistically Diverse (CALD)
Dandenong West Medical Centre in Dandenong
  • Over 65yo
  • Culturally and Linguistically Diverse (CALD)
  • Refugees and Asylum Seekers
The Hastings Clinic in Hastings 
  • Over 65yo
  • Homelessness
High Street Medical Centre in Cranbourne 
  • Over 65yo
  • Culturally and Linguistically Diverse (CALD)
Stud Road Medical Centre in Dandenong
  • Over 65yo
  • Culturally and Linguistically Diverse (CALD)
  • Aboriginal and Torres Strait Islanders (ATSI)
Wells Road Clinic in Chelsea Heights
  • Over 65yo
  • Culturally and Linguistically Diverse (CALD)

Each provider will deliver the following initiatives to at least 100 patients between June 2017 and June 2018:

  • improve access for at risk population groups to primary care services for the management of their complex and chronic conditions 
  • improve health outcomes for patients with poorly managed chronic conditions 
  • reduce the rate of Potentially Preventable Hospitalisations (PPH) for chronic conditions in the SEMPHN region, and
  • increase the efficacy of care coordination strategies to better manage chronic and complex conditions, and improve quality of life.

The Commissioning Process

An open tender process was used for the commissioning of services to improve outcomes for priority populations groups with complex and chronic conditions. Applicants registered via Tenderlink were invited to apply by responding to a series of questions, which were assessed against a set evaluation criteria by an Assessment Panel. Following assessment, the panel reached consensus in relation to the preferred provider.

More information

To hear about future commissioning opportunities, subscribe to our Commissioning Newsletter SEMaphore and register via Tenderlink here.

For general information or queries about commissioning, email This email address is being protected from spambots. You need JavaScript enabled to view it. .


Creating better links to primary care through community health services

In April 2017, Peninsula Health, Monash Health and Alfred Health were successful in receiving funding to create better links to primary care through their publicly-funded auspiced community health services. The total funding allocated was around $600,000 and the initiatives will run from approximately May 2017-18. 

OrganisationInitiative Description
Peninsula Health

Peninsula Health Community Care After Hours Care Diversion Project

This project extends the current Community Care program, which aims to support patients that frequently utilise hospital and/or at risk of
presenting to the Emergency Department (ED) by providing:

  • outreach care coordination;
  • medical consultancy; and
  • nursing and allied health interventions.

The funding grant will enable the program to operate from 9am – 9pm, 7 days per week. 

This initiative also:

  • supports effective discharge from ED;
  • assists to redirect patients to primary health care providers; and
  • enhances the hospital/ ED partnerships with Ambulance Victoria, General Practice and Residential Aged Care Facilities.
Monash Health

Redesign Of Residential In Reach (RIR) After-Hours Model

Nursing staff will be based at Dandenong Hospital ED between the hours of 9pm and 8:30am daily, supporting ED staff to facilitate appropriate transition and discharge of residents back to residential aged care facilities. 

Alfred Health

Better Integrated Care for Type 2 Diabetes 

Using integrated care pathways, patient education and support mechanisms, this model of care is aimed at optimising the ability of patients with Type 2 diabetes to self-manage their condition in the community particularly in the After Hours (AH) period by:

  • engaging a Diabetes Nurse Educator (DNE) to manage complex patients with type 2 diabetes;
  • implementing education and support programs to patients to self-manage their condition, particularly in the AH period such as Diabetes Education and Self Management for Ongoing and Newly Diagnosed (DESMOND), diabetic nurse educator and dietician assessment, use of an exercise program via an Exercise Physiologist; and
  • care coordination/case management to facilitate self-management for patients experiencing challenges due to complex health/social circumstances.

The commissioning process

Invitations were sent to auspiced Community Health Services (CHS) within the SEMPHN catchment as they are large providers of primary care, and have experience in delivering a multitude of preventable strategies. Each organisation submitted a proposal that was carefully assessed and considered by a panel comprising internal and external representatives. All three organisations were successful in their submission.


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Funding Opportunities

Tenders, Quotes & Expression of Interest Portal

If you’re interested in applying for funding opportunities, register your interest on SEMPHN's Tenderlink page. Once you register, you’ll receive information as it’s released.

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Events and Education See all

Training

Fellowship Preparation: KFP

External events
Saturday, 25 November 2017
9:00 - 15:00
Wantirna Health
General Practitioner

See event

Contact Information

Need help with Commissioning?

For more information about commissioning, please call 1300 331 981 (option 1) or email commissioning@semphn.org.au

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