The Capacity Tracker is a free, fast and secure online communication tool that enables General Practice (GP) and Residential Aged Care Facility (RACF) to quickly and easily contact our PHN.
The concurrent data allows PHN to identify trends and resource shortages, advocate, connect and coordinate support if required. The Capacity Tracker is currently being implemented by PHNs across Australia.
How does it work?
"The organisation enters contact details and indicates the level of risk for the admission, operations, Workforce, PPE and vaccine status by selecting a “Red, Amber or Green” system alert button.
Red: Significant impact, urgent response required
Amber: Some impact, swift response required
Green: No current impact, no response required
The Capacity Tracker will allow our PHN to identify and evaluate trends and issues across the region. This will enable us to provide support to our general practices and Residential Aged Care Facilities.
The collected data will allow our PHN to advocate, connect and commission services to address identified needs.
- Follow the link: https://au.capacitytracker.com/ and click "register now"
- Your facility is allowed to have several users or can only assign one person
- The GP and RACF registration videos will guide you through the registration and onboarding process:
Once you receive a confirmation of your successful registration, usually within one working day, and than you can start using the Capacity Tracker.
Mental Health Support for RACF
Improving GP access in RACFs
The PHN has identified a need to support the Central Queensland Community, and most specifically the Rockhampton community, in their current crisis around timely and appropriate access to GP care for residents in RACFs. This crisis is one that has been raised for the attention of our PHN by RACFs, the local Geri team, local GPs, our clinical council, HHS stakeholders, politicians, and individual consumers.
There are multiple angles this problem can be looked at and it will be important to consider the view of all involved parties in looking into the problem and considering workable solutions. We commissioned Central Queensland Rural Health (CQRH) to determine locally relevant and achievable strategies/action to increase access to GP and wider primary health care for residents of Residential Aged Care Facilities in the Rockhampton region using evidenced based planning processes.
The report will be delivered by CQRH in June 2022.
Falls Prevention Initiative
In consultation with Queensland Ambulance Service (QAS), Central Queensland, Wide Bay Sunshine Coast Primary Health Network (PHN), Hervey Bay Neighborhood Centre (HBNC) and Wide Bay Hospital and Health Service (WBHHS), falls have been identified as a potentially preventable population health issue and health system burden and a high impact area for service improvement. World Health Organization (WHO) definition of a fall is ‘an event which results in a person coming to rest inadvertently on the ground or floor or other lower level’.
The introduction of a Wide Bay Falls Prevention Service will provide the community of Fraser Coast the equity and access to falls intervention pathways, offering rabblement support and bridging of services through assessment, planning, coordination, and community pathways in line with the consumer’s goals and needs. In the form of targeted and multifactorial intervention, case-coordination, strength and mobility program, community peer support and education group models will be offered. This service will improve health and wellbeing in this cohort, reducing the personal and system burden related to falls in community-dwelling consumers.
This pilot project will be based on the Fraser Coast from April 2021 to April 2022.
- 12 month funded program
- Bookings are made through the provider of the Active @ Home Program
- Delivered by Patient Care Workers and supported by the Registered Community Nurse under the Community Nurse In-Home Falls Assessment and/or Registered Nurse Navigator from WBHHS
- Group, Centre-based Lifestyle Café/Active at Home program
- Where: Hervey Bay Neighbour hood Centre
- When: Once per week, 2 hour sessions
- Cost: Co-contribution ($5 for morning tea), Transport ($10 for TransComCare or $5 for HBNC bus),
- Transport: arranged by the consumer through HBNC community bus or TransComCare
Note: Where consumers identify financial hardship, the Nurse Navigator Service via the WBHHS will flag this with the HBNC for fee wavering and support to access Lifestyle Café and transportation.
The PHN is funding the up skilling of personal care workers to deliver a home-based strength and balance exercise program (Active @ Home) to improve functional wellbeing to people aged over 65 years or people aged over 50 years where the person identifies as an Aboriginal or Torres Strait Islander, receiving in home care.
- Active at Home is a 12-week program
- Delivered by Patient Care Workers
- Where: In-home, individual, one-on-one
- When: Once a week
- Cost: Privately funded or through Commonwealth funding
- Note: 12-week program with an opportunity to extend if required
The PHN contracted community Registered Nurse will review, assess, and coordinate non-complex referrals, ensuring identified patients have access to individualized community-based care pathways, targeted and multifactorial intervention while optimizing available Commonwealth, State and WBHHS strategies and resources.
They will also provide access to strength and mobility programs (Active at Home) and the community peer group (Lifestyle Café).
They are responsible for:
- Contacting and reviewing the patient in their home within three working days unless identified as a higher priority by the WBHHS
- Biopsychosocial assessment of the patient and environment to inform coordination of care and shared decision making
- Multifactorial and interdisciplinary care approach
- Referring patients to appropriate services as needed
- Coordinating comprehensive care for patients, articulated in a patient-centered care plan
- Provide evidence-based and individualized falls prevention interventions
- Working collaboratively with all involved health care professionals and relevant services, including, but not imited to GP’s, Allied Health, Queensland Health, QAS, NGOs, private providers, NDIS and MAC
- Complete 3 monthly and 6 monthly reviews as clinically required
- Assist in coordinating the community peer group sessions in conjunction with the HBNC and WBHHS
- Communicate all assessments and interventions to client's primary GP and the WBHHS Nurse Navigator service via a secure file transfer system
Clinical handover is the transfer of professional responsibility and accountability for some or all aspects of care for a patient to another person or professional group. It involves the transfer of patient information between individuals or groups and is an important part of clinical care.
Webinar and Practical Guidebook
To help clinicians, predominantly in residential aged care facilities, provide effective clinical handover consistent with relevant Standards, the PHN has produced the following resources:
- Practical Guide for Clinical Handover in Residential Aged Care Facilities
- Accompanying short webinar outlining best practice for RACFs on clinical handover to general practice
Residential aged care MOU templates
LASA has released formalised agreement templates for residential aged care providers to use with GPs and hospitals. These templates aim to improve care outcomes and lower transaction costs by clarifying roles and responsibilities and improving communication.
Each template can be adapted to individual RACFs circumstances:
Supporting Advance Care Planning
The PHN has commisioned the Office of Advance Care Planning to support support the Advanced Care Planning (ACP) process within communities across the CCQ region. Investing in Advance Care Planning is recognised as an important component of quality patient centred care, ensuring the individual’s wishes and values are documented and respected.
You can find further information on Advance Care Planning:
- What is Advance Care Planning?
- How to complete an advance care plan?
- or contact our team firstname.lastname@example.org.
Order your Advance Care Planning Pack here.
In collaboration with local early learning centres, kindergartens and schools, the Moving Moments Program connects seniors and children of all ages. Together, you will make wonderful memories and build long lasting friendships.
Moving Moments is an exciting program for seniors and children of all ages, our all inclusive sessions run in Biloela, Caloundra, Hervey Bay, Buderim and Gympie.
Visit the Moving Moments website for further information.
Watch the ABC Sunshine Coast news piece: Moving Moments as Queensland seniors and children connect in intergenerational program.