Annual Report 2021-2022

See pdf version here.

We continue to have an instrumental role during the COVID-19 response through crucial engagement and information to health professionals and the community, supporting the vaccination program for GP practices and aged care facilities, vulnerable groups and Commonwealth funded general practice respiratory clinics (GPRCs), distribution of personal protective equipment and promoting vaccination to improve uptake, through engagement and communication campaigns. 

COVID-19 Response: Continue Reading

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Support to General Practice

• We have provided ongoing support to general practices during the vaccination program, assisting with inquiries relating to COVID-19 vaccine allocation, ordering stock, cold chain management, information materials and keeping GPs informed about any updates to ATAGI State and Commonwealth advice.
• During the past 12 months, the team has prioritised same-day updates to frontline primary care staff. COVID-19 testing and COVID-19 vaccination pages accounted for 34.46% of total website page views during the 12-month period.
• We have provided general practice with valued resources for GPs and consumers about the pandemic, including important website tools such as the COVID-19 management pathways.
• GPs, practice managers and practice nurses say that our COVID-19 updates and our website information has been a valued source of truth they have relied on during the pandemic.
• We distributed 14,100 COVID-19 patient leaflets (Medicare, Get proof of your COVID-19 Vaccination) and 14,150 COVID-19 vaccination appointment cards to general practices participating in the COVID-19 vaccine program. These resources provide information to patients on when they received their COVID-19 vaccine and how to access their immunisation record from the Australian Immunisation Register. We also provided leaflets to all general practices and respiratory clinics to provide to their patients, about what to expect after receiving a COVID-19 vaccination.
• In collaboration with Gold Coast Health, we have continued to assist staff in the primary care sector to receive their COVID-19 vaccinations.
• We have continued to support GPRCs at Nerang, Upper Coomera, Burleigh Waters and Hope Island, which provide a safe environment for assessment and testing of respiratory symptoms including COVID-19.
• From January to June 2022, GPRC staff provided face-to face services to COVID positive patients requiring care that couldn’t be provided by their usual GP, didn’t have a usual GP or were Medicare ineligible.
• To support primary care GCPHN commissioned specific clinical, mental health, alcohol and other drugs and wound management services for COVID positive people from January to June 2022. These services were commissioned in collaboration with Gold Coast Health.
• We hosted 13 COVID-19 events and seven COVID-19 webinar updates for Gold Coast general practice with an average of 67 attendees. We were also involved in a COVID-19 state-wide GP update with 163 attendees and organised five COVID-19 educational events with an average of 20 attendees per event.
• To address identified workforce issues including increased patient hostility and burnout, we partnered with General Practice Gold Coast to deliver resilience training for the GP workforce.
• We partnered with Griffith University to deliver three sessions of Consumer Hostility training for frontline general practice and RACF staff.

PPE Distribution

• We continue to play a key role in the distribution of personal protective equipment (PPE) for general practice, pharmacies and allied health professionals, where commercial supply is not available.
• This has been a significant logistical exercise, with solid internal processes in place and we successfully transitioned to a new ordering process implemented for Living with COVID bundles, which included pulse oximeters and emergency PPE provisions.
• In October 2021, we organised fit testing for general practice and respiratory clinic staff requiring P2/N95 masks. A total of 522 individuals were fit tested across 67 practices.
• In the last 12 months we distributed 60,640 surgical masks, 9,808 P2/N95 masks, 5,120 gowns, 4,470 goggles and 29,900 gloves.

Vaccinating vulnerable groups

We have been involved in supporting the vaccination of vulnerable populations including people who are homebound, homeless, have mental health/substance abuse issues, people of non-English speaking backgrounds and the Aboriginal and Torres Strait Islander community. This has been through supporting in-home vaccination services, group and mobile vaccination clinics and widespread education and promotion, to encourage uptake of the COVID-19 vaccination. Our work has included:

• Implementing three SMS patient recall campaigns for general practices, to directly promote COVID-19 and Influenza vaccinations to First Nations and culturally and linguistically diverse (CALD) communities and vulnerable patients.
• Commissioning GP services to provide mobile vaccination clinics for homeless people or people at risk of homelessness, resulting in 176 doses administered. We also supported an additional six vaccination clinics.
• Providing in-home vaccinations to housebound people resulting in a total of 67 COVID-19 vaccinations.
• Providing 33 mobile or inreach COVID-19 vaccination clinics for vulnerable people and for people with substance abuse, mental health issues and CALD groups.
• Successfully increasing primary vaccination rates for specific targeted CALD groups including Portuguese to 79.9%, Spanish to 81%, Japanese to 84.7% and Mandarin speakers to 89.8%, higher than the Queensland average.
• Working collaboratively with Gold Coast Health and Kalwun on a wide-reaching campaign, promoting Indigenous COVID-19 vaccinations including vaccination opportunities at targeted events, promotional materials for school clinics, letterbox drops, social media and the development of customised video content with a local Indigenous community leader. As a result, vaccination rates for Aboriginal and Torres Strait Islander Peoples were 82.6% (primary vaccination) and 80.7% (2nd dose) which is above the state average.
• Providing leadership, guidance, and local insights at a range of Gold Coast and state based weekly/fortnightly stakeholder meetings including Queensland Police, Queensland Council of Social Services, Mater Refugee Services, Queensland Primary Health Networks and Gold Coast Health.

Residential Aged Care Facilities

• Successfully coordinated and facilitated the Commonwealth mandatory staff vaccination program across Gold Coast residential aged care facilities (RACFs) resulting in a 98.2% primary dose vaccination rate for the Gold Coast.
• Coordinated and facilitated 75 COVID-19 vaccination in-reach clinics for RACF residents and staff to administer primary, booster and winter doses.
• Facilitated successful COVID-19 winter dose mop up clinics in collaboration with Commonwealth Vaccination providers the Gold Coast Health Public Health Unit, across 30 facilities, resulting in 1205 COVID-19 doses administered.

Stakeholders

We would like to acknowledge the significant collaboration with our partners and stakeholders in the continued COVID-19 response.

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Mental Health Suicide Prevention and Alcohol and Other Drugs 

Joint Regional Plan

The Joint Regional Plan (JRP) for Mental Health, Suicide Prevention and Alcohol and Other Drugs (AOD) was launched in 2020 as a joint initiative with Gold Coast Primary Health Network (GCPHN) and Gold Coast Health (GCH) in collaboration with clinicians, service providers and people with a lived experience. 

The plan is a roadmap for our shared activities which align with regional strategic needs and priorities, to ensure people can live life with meaning and purpose within a compassionate, connected and diverse community.  

To support the implementation of the Joint Regional Plan, partnership groups have been established bringing together service providers, individuals with lived experience and key stakeholders who report to the Strategic Oversight Committee. Their combined knowledge will help to consider needs from within the plan to assist people living with severe and complex mental health, alcohol and drug concerns and support suicide prevention. 

In the last 12 months the following has being achieved under against the key focus areas of the Joint Regional Plan. 

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Leadership, governance and partnership, including lived experience 

• Joint funding and implementation of a Joint Regional Plan Coordinator role. 
• Progressing the Crisis Reform Strategy, including co-commissioning of the After-Hours Safe Space Initiative providing alternatives to hospital emergency departments.

Planning for a common agenda 

• Rapid establishment of COVID-19 service responses for patients who required mental health, drug and alcohol and suicide prevention support, building on existing relationships and commissioning arrangements. 
• Leveraging the overarching data sharing agreement between GCH and GCPHN to more effectively plan and evaluate services (e.g. suicide prevention services, After Hours Safe Space, Local Area Needs Assessment). 

Coordinated activities that leverage and enhance strengths 

• Embedding regionally agreed upon access and information points (e.g. HealthPathways, Alcohol and Drug Information Service) as a central point of reference for services. These access points ensure patients and clinicians can more efficiently navigate the system and connect to the most appropriate level of care. 
• Implementation of service and process improvements to improve the transition of care for consumers being discharged from GCH into community Alcohol and Other Drug Residential treatment. 
• Building capability and capacity of primary care providers to support opioid treatment program patients in the community, reducing GCH caseload. 
• Development of interagency protocols for the referral and clinical care of young people between our funded services and GCH mental health services, leading to a more consistent approach to intake, assessment and referrals to enhance client care. 

Responsive and connected workforce 

• Development of the peer (lived experience) workforce, through a defined growth strategy and implementation of the Peer Practice Supervision Implementation Plan. 
• Joint funding and facilitation of shared development and networking sessions including an annual regional symposium for 220 clinical and non-clinical staff from both GCH and community organisations. 

Effective, timely and safe information exchange 

• Continued to support restricted non-government organisation (NGO) access to the Gold Coast Health data system (CIMHA) to support the transition of care between Gold Coast Health and NGOs.  

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Suicide Prevention Implementation Group

The Suicide Prevention Implementation Group (SPIG) was established in 2022 as one of the Joint Regional Plan partnership groups. This group was established to progress the Suicide Prevention Community Action Plan which was launched in 2021, developed by Gold Coast Primary Health Network (GCPHN) and Gold Coast Health (GCH) with support from networks, community groups and individuals with a lived experience. This plan, together with the SPIG, strengthen relationships and collaboration in the planning, coordination and implementation of suicide prevention activities for the Gold Coast. It is intended to foster supportive social relationships, encourage effective help seeking and positive connections of health services, and support family harmony and a sense of purpose and control. 

Alcohol and Other Drugs

Statewide Review – Alcohol and Other Drug Services

The Queensland Alcohol and Other Drug (AOD) Network has completed a state-wide mapping process of all AOD services and funding to define improvements in commissioning, service quality and service outcomes.  Key recommendations achieved in the review in 2021/22 are:

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• QLD PHNs and sector agencies/peak bodies to participate in joint planning around AOD service delivery ensuring that suitable governance and processes to achieve best practice planning are in place.
• QLD PHNs to consider a dedicated staff resource to liaise with Queensland Health and other funders to enable central decision-making (e.g., taxonomy development, planning frameworks and guidance, Aboriginal and Torres Strait Islander commissioning, model, and dataset management).

Alcohol and Other Drugs GP Support

The Alcohol and Other Drugs (AOD) GP support project aims to support the delivery of drug and alcohol training packages to the primary health care sector, including supporting GPs and other health professionals to enhance their knowledge and application of the AOD referral pathway and increase awareness of evidence-based resources to improve drug and alcohol addiction treatment.

Achievements

• Consolidation of AOD education and training packages.
• Ongoing promotion of the RACGP and ACRRM education packages through the GCPHN GP Bulletin.
• Update of AOD resources for health professionals on the GCPHN website.
• Development and delivery of information webinars to Gold Coast GPs. Key topic areas covered in the webinars were:
• Overview of AOD Screening CQI toolkit for GPs
• Education of the Health Pathways system and associated AOD pathways
• Assessment/screening of patients with problematic alcohol use
• Overview of local resources and referral options in Gold Coast region
• Overview of the Community Withdrawal Program and associated referral pathways
• Development of information/education vignettes (short videos) across key community based AOD providers in the Gold Coast region.

Stakeholders

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Child and Youth

Strengthening Health Assessments Pathways for Children and Young People in Care

The Strengthening Health Assessments Pathways for Children and Young People in Care is a Queensland-wide project aimed at improving both the child safety and health sector response to the health care needs of young people in care.

Funded by the Department of Children, Youth Justice and Multicultural Affairs until 2023, Primary Health Networks across the state and child safety services centres are leading this key system reform at a local level.

This includes ensuring that GPs are applying the National Clinical Assessment Framework for Out of Home Care, improving access and timeliness of health assessments and improving integration and information sharing between health practitioners, the Department of Child Safety, families and carers.

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Achievements

• 257 children are on the health assessment pathway with 76% of children recording improved health.
• 117 GPs have conducted health assessments for children new to care since the project commenced.
• COVID vaccinations for young people in care have been supported.
• Increased awareness of Kalwun health services for the child safety system through clinic tours. Kalwun has been providing care coordination support to Indigenous participants to assist with completion of health assessments.
• Training delivered to healthcare providers and carers covering youth mental health first aid, children at risk during COVID-19, quality improvement, community of practice on disability and complex needs, Foetal Alcohol Spectrum Disorder, carers workshop and screening of a resilience documentary at the Gold Coast Mental Health Symposium.

Stakeholders

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Primary Sense

Primary Sense is a population health, data extraction, analysis, reporting and decision assist tool for general practice that has been pioneered by Gold Coast Primary Health Network (GCPHN). Its’ wide-reaching success locally has seen it being rolled out at a national level. GCPHN is supporting the WA Primary Health Alliance (WAPHA) to implement this national rollout with 17 Primary Health Networks providing funding for a national scaled version of Primary Sense. Ten PHNs nationally (including Gold Coast) are planning to transition to the national, scale version of Primary Sense by June 2023.

This toolset assists general practices to identify patients most at risk of poor health or disease and provide targeted interventions to reduce their risk of becoming unwell or experiencing a preventable hospitalisation.

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Achievements

• Johns Hopkins University is assisting with the national scale business case and build.
• WAPHA re-engaged directly with Medical Director and Best Practice for the national scaled version.
• 93% of eligible general practices had Primary Sense installed by June 2022 following, an intensive engagement approach from January 2022.
• The value add for general practices was indicative of the high interest and installation rates, despite this period falling during the height of the Omicron outbreak on the Gold Coast.
• Primary Sense poster presentation featured in the July 2021 World Organisation of Family Doctors International Conference.
• Overwhelmingly positive feedback has been received from practices about the ease of use of Primary Sense which contributed to the overall success of the roll out.

“It’s great to know the Primary Sense prompts I receive are specific to each patient and so easy to action.”
– General Practitioner

Stakeholders

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Suicide Prevention

In partnership with Queensland Health, we fund the Way Back Support Service, run by Wesley Mission Queensland, which provides three months of tailored non-clinical psycho-social support to people who have recently attempted suicide or are at risk of suicide, who have been admitted to Gold Coast Health hospitals.

Support facilitators guides participants through their recovery including helping build a personalised safety plan and linking them to health and community services and clinical care if needed.

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Achievements

• In the last 12 months, there were 683 clients participating in the service.
• From 211 episodes of care, 72.5% reported significant improvement.
• The Gold Coast site was the first to establish and set up successful Consumer Integrated Mental Health and Addiction (CIMHA) data sharing access between the service and Gold Coast Health, now being championed across the state.
• Following discussions with Queensland Health and Beyond Blue, Wesley Mission Queensland continues to manage high demand to ensure a safety plan is developed and a point of contact is maintained. As a result, 100% of clients continue to be followed up within one working day.
• The Way Back Support Service has been recognised by Beyond Blue and Queensland Health for its strong collaboration between key stakeholders.

Service Provider

• Wesley Mission Queensland

After Hours Safe Space

To support people in the Gold Coast community who may experience mental health concerns outside regular business hours and as an alternative to emergency department presentations, we have established After Hours Safe Space services which operate after hours. The first service was opened at Mermaid Beach in 2018.

In response to high demand and with Queensland Health funding, we worked with Gold Coast Health (GCH) for another low to moderate intensity community-based service. Through co-design with GCH, we further developed our regional model and launched a new service in Southport in late 2021. The Mermaid Beach service remains operational with some changes to align with the Southport site. Both sites are operational seven days a week. Consumers can walk into a warm and welcoming café style environment with access to face-to-face supports form lived experience workers. Additional support is available from a specialised mental health clinician if required.

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Achievements

• During the past 12 months, just over 2,800 people sought support through the Gold Coast After Hour Safe Spaces.
• The service provides support to those trying to de-escalate when they feel they may be becoming unwell. 33% of service users have identified attending the after-hours service as an alternative to seeking support through hospital emergency departments.
• While the service provides support around various needs, 32% reported an improvement in mood after accessing the services for support.
• The service is free and accessible to all people experiencing a mental health concern regardless of existing supports, as such a small percentage (2.8%) of those accessing supports reported being consumers with access to NDIS supports.

Service Providers

• Primary and Community Care Services (PCCS)

Stakeholders

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Chronic Disease Services  

Turning Pain into Gain

For the last eight years we have commissioned PainWise to run the Turning Pain into Gain program which has been heralded as life changing by participants.   

The program provides pain management services to patients through a multi-disciplinary team including a GP, pharmacist, dietician, pain educators, counsellor and psychologist. It also provides individual and group sessions either face-to-face or through telehealth services.   

 The program also delivers training to healthcare professionals to ensure their knowledge and skills on pain management are up-to-date.   

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 Achievements 

• In the last 12 months, 301 clients have accessed the service.  
• There was increased demand from flood affected and regional areas, with 8% of referrals accepted from Northern NSW.  
• Highest referrals were from the southern Gold Coast region and in the ages of between 25-29 years, followed by 45-49 and 30-34.
• The program has a 70% completion rate by participants with 100% patient satisfaction, with a waitlist less than six weeks. 
• A world first Subacute Early Intervention Pain Program was piloted between July 2021 and June 2022 to provide an early intervention service to prevent the development of chronic pain.  The overall program significantly improved pain-life interference scores, accounting for 33% of the improvement recorded.  
• The program has developed a strong health professional network with inter-referrals between local hospital services (public and private) and community-based services for faster access and care navigation. 

 Service Provider

• PainWise  

 Stakeholders 

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Integrated Team Care

The Integrated Team Care Program has been improving healthcare coordination for Aboriginal and Torres Strait Islander community members in the Gold Coast region for many years. The program has two service areas, one which provides support and service for people with long-term chronic health conditions (complex care pathways) and the second program focussing on support. 

The program is commissioned through Kalwun Development Corporation and includes Indigenous project officers, outreach workers and care coordinators, who aim to close the gap in life expectancy by improved access to culturally safe mainstream primary, community and tertiary healthcare services for Aboriginal Torres Strait Islander people.  

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Achievements

Healthcare support 

• 15,426 services delivered to 250 patients including: 
  • 2,138 care coordination services 
  • 8,227 supplementary services 
  • 5,061 clinical services accessed 

Transport services  

• 401 transport services were accessed by patients which included: 
  • 7,490 allied health appointments including exercise physiology, podiatry and dental. 
  • 423 specialist appointments including rental, endocrinologist and respiratory. 

Cultural awareness training 

• Engaged with 117 general practice staff through cultural awareness activities and engagement events, to improve the cultural competency of mainstream primary healthcare services. 
• Successfully delivered three cultural awareness training sessions, with 47 attendees. 

Service Providers

• Kalwun Development Corporation 
• Institute for Urban Indigenous Health 

Stakeholders

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Wound Management

Wound Management Pilot Residential Aged Care

We were one of three Primary Health Networks nationally to receive funding for a wound management pilot. This program supports people living in Residential Aged Care Facilities (RACFs) with chronic wounds, with the intent to build the capacity of RACF staff to deliver evidence-based wound care onsite.

The project is led by an experienced Wound Management Nurse Practitioner and includes:

• Access to funded online and face to face workshops for wound training
• Onsite and telehealth consultations for residents with complex wounds providing a mentor model for RACF staff to build confidence in managing future wounds.

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Achievements

• 55 Gold Coast RACFs participated in the service
• 111 residents accessed the service
• 102 RACF staff have participated in education and training events

Stakeholders

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Chronic and Complex Wound Care

We fund a dedicated primary care based wound clinic led by a wound specialist GP and nurse practitioner, who are supported by a team of highly trained nurses. The Chronic and Complex Wound Clinic supports local GPs and their patients to improve health outcomes with people that have chronic, complex, recurrent and debilitating wounds that seriously impact their quality of life.  

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Achievements

• 107 people accessed the service in the last 12 months, with 928 occasions of service. 
• Of the 75 patients who exited the program, 52 left with a fully healed wound.  
• Exceeded target wait times of less than seven days with average wait times from referral to assessment, on average, only three business days.
• Due to the success of the wound clinic, this model of care is being reviewed in locations in Brisbane and the Sunshine Coast.  
• Through education and training, there has been significant improvement in the quality of referrals received at the clinic, supported by a template that was developed to ensure appropriate information was included to facilitate timely care. 

Service Provider

• Dr Stephen Yelland (sole provider) supported by Nicola Morley Nurse Practitioner   

Stakeholders

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Wound Education and Training Program for GPs and Primary Care Nurses

The Wound Education and Training Program offers training and education that will increase confidence, knowledge and skills of GPs and nurses responsible for the care and management of patients living with chronic and/or complex wounds in general practice or residential aged care settings.  

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Achievements

• Despite the restrictions created by COVID-19, two nurse and two GP workshops were completed  
• Total number of attendees at the four workshops included: 
• 25 nurses  
• 22 GPs 
• Evaluation results from all workshops indicated that all learning objectives were either fully or partially met with a keen interest for further training opportunities  

Service Provider

•  Dr Stephen Yelland (sole provider) supported by Nicola Morley Nurse Practitioner   

Stakeholders

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Intake, Referral, Service Navigation

Gold Coast Referral and Triage Service

The Gold Coast Referral and Triage Service has been a central point for receiving and assessing referrals for people requiring mental health and suicide prevention services that are not in crisis. In the last 12 months the service has:

• received just over 2,900 referrals
• 96% were responded to within 3 days (or 1 day for suicide prevention referrals)
• 393 required follow ups were initiated.

From July 1, 2022, this service has transitioned to the Gold Coast National Head to Health Intake and Assessment Phone Service.

Expanded Horizons

The Expanded Horizons Program is a peer led program that works to ensure young people in the Gold Coast region that identify with the LGBTIQAP+ community have a place of connection and access to psychosocial programs and supports. The program offers resources, guest speakers, peer support and information to build a positive sense of identity and connection.

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Achievements

• 63 group workshops have been delivered to 553 attendees.
• Individuals reported improved health and wellbeing regarding employment, study and independent living skills.
• Clients and supporters have reported that digital intakes have been helpful for increased accessibility.
• Young people have participated in local art and slam poetry competitions, mental health and wellbeing workshops in partnership with other organisations and LGBTIQAP+ community events such as Pride GC and the Trans Day of Visibility.
• QSPACE has been featured in an educational Wesley Mission Queensland video to be distributed to schools in the Gold Coast region.
• Development of professional and community partnerships in the region has increased interest about the program. Increased capacity-building enquiries from families, health professionals and the wider community have been received regarding best practice when working with LGBTIQAP+ communities.
• Positive feedback has been received about the service provider from clients, family and carers, schools, health and hospital services and other external stakeholders.
• Clients who have been presenting with complex needs (e.g., people with ASD, ADHD, or physical disabilities or domestic violence) with high demand for individual support, have been supported through new partnerships with Carers Queensland, LGBTI Legal Service, and QuAC.

Service Provider

• Wesley Mission Queensland

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Community Pathway Connector

The Community Pathway Connector program simplifies and improves the process to connect services for members of the Gold Coast community requiring culturally appropriate mental health and well-being services. CURA has been providing services for people from culturally and linguistically diverse backgrounds and Krurungal, for Aboriginal and Torres Strait Islander peoples. The service connects people of any age with mental health and wellbeing services, removing any barriers to ensure they receive culturally safe access to support services.

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Achievements

• A total of 449 people have accessed the services in the last 12 months. This includes support for 149 people through CURA and 300 people through Krurungal.
• CURA has achieved close to 100% of its annual target for people accessing the program. Of those, 91% have been referred to appropriate supports.
• The main concerns for CURA clients has been mental health, followed by housing, accommodation needs and homelessness.
• Outreach group work is delivered in multiple community areas, such as Talking Circle (female English language practice) and Wellness and Mental Health Recovery groups.
• Krurungal client numbers are exceeding targets and good numbers of new referrals are received each quarter.
• The primary needs of clients accessing Krurungal services are food, clothing, housing, accommodation and transport.
• Due to weather events of 2022, Krurungal has provided significant support to a large influx of clients, requiring flood relief.

Service Provider

• CURA
• Krurungal

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Mild to Moderate Intensity Mental Health Programs

Psychological Services Program Review

We have progressed work on the Psychological Services Program review to establish a new service model in late 2022, with a focus on identifying areas for improvement in the following key areas:

• timeliness of service commencement
• expansion of geographical spread of service provision
• prioritisation of specific cohorts and consideration of changes to these cohorts over time
• workforce capability to service specific priority groups
• managing flow of referrals to increase patient experience and reduce administrative burden.

headspace (Primary)

headspace provides a range of services to improve the health and wellbeing of young people aged 12-25. This includes mental health and wellbeing, physical and sexual health, work and study support and alcohol and other drug services.

We commission Lives Lived Well to run headspace Southport and headspace Upper Coomera, which opened in July 2020.

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Achievements

• Both headspace centres are operating well above the national average with 2,892 young people accessing headspace Primary services for the 12-month period across the Gold Coast region.
  • headspace Southport provided services to 2,036 young people
  • headspace Upper Coomera provided services to 856 young people
• The headspace Early Careers Program continues to be engaged at both sites. This initiative was developed to attract allied health graduates to work in youth mental health, to grow the allied health professional workforce for headspace into the future.
• The headspace Southport, headspace Model of Integrity Framework assessment, completed by headspace National Office, identified that the service passed all requirements to successfully meet accreditation benchmarks.

Service Provider

• Lives Lived Well

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Psychological Services in Residential Aged Care Facilities 

With approximately 39% of all permanent aged care residents living with mild to moderate depression, and as a national priority, we commission Change Futures to provide psychological support to residents in residential aged care facilities (RACFs). 

The service supports residents experiencing mild depression of anxiety and those having trouble adjusting to changes or coping with loss. The service can also support people experiencing dual diagnosis of mental health and dementia or brain injury/development disability, where behaviours are identified as mental health related.  

Sessions can be focused on transitions into aged care, engagement and wellbeing and managing identified mental health conditions. 

COVID-19 has presented considerable challenges for residents with additional lockdown measures, increasing feelings of isolation and anxiety and in these instances, support has continued through telehealth options.  

“We very much appreciate Change Futures coming to us. Our residents benefit from your services greatly. The practitioner that visits our facility is very professional and assists our resident with depression and anxiety especially during COVID times. Our residents often express positive thoughts after sessions with your practitioners. Not only does this benefit the care staff, but also benefits the residents, their families, and the community. Thank you.”  – RACF Clinical Manager  

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Achievements 

• All 57 RACFs the Gold Coast region are now engaged in this program, which is 100% engagement. Active clients fluctuate with referrals in and out of the service.  
• There have been consistently high referrals with 682 people accessing the service in the last 12 months, and 4,168 service contacts delivered. 
• 52.7% of clients experienced significant improvement (from 203 episodes of care) 

Service Provider

• Change Futures 

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NewAccess 

Developed by Beyond Blue, NewAccess is a low intensity mental health coaching program, designed to provide accessible, quality services for anyone finding it hard to manage life stress. People can access six coaching sessions either face-to-face, telephone or video link. Coaches assess the person’s needs, then work with them in setting practical, effective strategies to help them get back on track. 

“Prior to the program I questioned whether my feelings were valid but since talking to you I know they are legitimate and valid which feels good to acknowledge that. If those feelings do come back, I will now be more aware of what is happening, and I will be a step-in front of them after the program as I now have new tools and strategies to help.” – Client 

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Achievements

• 350 people have accessed the service in the last 12 months. 
• 88% of clients reported having progressed against the goals established. 
• 98% of clients reported positive satisfaction with the service. 

Service Provider

• Primary and Community Care Services 

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High Intensity Mental Health Programs

YOUTH CLINICAL CARE COORDINATION 

Lighthouse and headspace Early Psychosis Program 

headspace Early Psychosis supports young people aged 12-25 at risk of, or experiencing, their first episode of psychosis. In addition, the Lighthouse multi-disciplinary team works with young people aged 12-18, providing longer term support to help them better manage the impacts and symptoms of past complex trauma and work towards creating positive life changes.  

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headspace Achievements 

• A new Clinical Services Manager has been appointed with oversight of headspace Early Psychosis, headspace Primary and Lighthouse.  
• Notice of the Early Psychosis service being funded until June 2025 has allowed for the commencement of recruitment of key positions and will allow a further focus to improve current standing caseloads to grow with confidence to meet the incoming financial year’s targets.   

Lighthouse Achievements 

• Eighty-nine young people accessed the Lighthouse service in this 12-month period. 
• 63.6% of clients reported significant improvement (based on 22 episodes of care). 
• The successful completion of Orygen Youth Enhanced Services lab in June provided an opportunity to receive 12 months of on-site and remote support from the Orygen youth mental health team, contributing to the successful redesign of the service pathway. 
• The service has now been co-located to the headspace Southport building, offering better access to broader resources for the Lighthouse team and streamlined access for clients.  

Service Provider

• Lives Lived Well 

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Clinical Care Coordination (Plus Social)

The Clinical Care Coordination program provides holistic, high-intensity support services for those living with the impacts of complex and mental illness. Through comprehensive care co-ordination, clients are supported towards recovery.

A multidisciplinary care team (of mental health professionals) support clients to achieve their identified goals holistically by including and addressing social determinants of health and key life stressors such as housing, financial issues, unemployment, health issues, lack of appropriate mental health clinical supports, access to benefits, transport and legal issues, and feeling connected to others in community. This promotes stabilisation of mental health and empowers self-efficacy and quality of life.

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Clients require a GP or private psychiatrist referral to access the service and are then offered brief to moderate length supports which includes a holistic needs assessment, customised care planning, and referrals to appropriate locally based (public and private) health and social services and enrolment into social activities etc. Most clients receive support for 3-9 months, ensuring a stepped care approach that recognises the variability of an individual’s mental ill-health presentation at any one time, and that a continuum of service interventions is necessary to offer the right service at the right time.

While in the program, clients may seek assistance to apply for NDIS supports. When support has completed, clients can be on-referred for ongoing supports as required to moderate or low intensity services.

Achievements

• 522 clients have accessed the service, with client satisfaction at 96%, well above the initial target of 70%.
• A total of 56 clients have been supported to test for NDIS eligibility, and 82% of these clients were found eligible and supported to transition into NDIS supports.

Service Provider

• Primary and Community Care Services

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Psychosocial Support Program 

The Psychosocial Services program is a non-clinical service providing low to moderate intensity individual and group activities to support people to achieve their mental health recovery goals.

The service offers a range of group activities that aim to build capacity and stability in areas such as:

• social skills and friendship building opportunities
• family connections
• managing daily living needs, cooking etc.
• finding and maintaining a home
• vocational skills and goals, volunteering
• education and training goals
• maintaining physical wellbeing and exercise
• managing drug and alcohol addictions
• building broader life skills including confidence and resilience
• Exploring purpose and meaning.

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Achievements

• In the last 12 months, the program has seen 316 active clients, with 3,836 service contacts.
• 93% of program participants reported positive satisfaction with the service.
• Twenty clients were supported to test for NDIS eligibility with 19 found eligible and transitioned to NDIS support.
• Clients on a waitlist for clinical care supports who received individual or group support while waiting, reported they were able to manage their concerns and were no longer needing clinical supports.

Service Provider

• Primary and Community Care Services

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QuIHN Community Withdrawal Program

With a number of alcohol and other drug (AOD) services on the Gold Coast at capacity and the difficulty for many people to access residential services due to family or work commitments, this pilot program provides more accessible options for people with symptoms of AOD withdrawal. 

Individuals are supported to withdraw from a range of substances in their own homes with the support of specialist AOD clinical staff, family and support person, or at the service. 

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Achievements

• 187 people accessed this service  
• 100% of clients reported satisfaction with this service and all clients who completed treatment experienced improvement. 
• Continued increase in referrals due to promotional activities.  

Service Provider

• QuIHN (Joint funder with GCPHN) 

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AOD continue reading:

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After Hours AOD Program

This program provides community-based alcohol treatment services on the Gold Coast for adults aged 18 years and over.  This service is for individuals that are experiencing substance related disorders who find it easier to access services out of usual business hours. 

Achievements

• 932 people accessed both these services exceeding annual targets. 
• An average of 73% of clients reported significant improvements in clinical outcomes and almost 100 % of people report satisfaction with these services. 
• Ability to reach consumers who are working or have other responsibilities in daytime hours such as childcare.  

Service Provider

• Lives Lived Well 
• QuIHN 

Kalwun Social Health Clinical Care (Alcohol and Other Drugs)

This low to high intensity service offers comprehensive support for Aboriginal and Torres Stair Islander people who are experience some mental health challenges or for those alcohol and other drug needs. The program works within a social and emotional wellbeing framework and provides clinical and non-clinical treatment. 

The services empowers people to self-manage and make decisions about their own health at their own pace. The Social Health Team offers a person and family approach to providing care and can link clients to a range of internal and additional services. 

Achievements 

• 335 people accessing the service  
• 100% of all service contacts were culturally appropriate for Indigenous clients 

Service Provider

• Kalwun Development Corporation 

Community Based AOD Treatment

This program provides Gold Coast youth and adults, a range of service options to support their needs through community-based alcohol treatment services. Support is also available for their families/carers. Service streams offered are family therapy and support, youth outreach, transition support (from AOD residential treatment to community living) and youth dual diagnosis. Treatment options are provided through outreach, co-location arrangements and a centre-based service delivery at Burleigh Heads and Nerang.   

Achievements   

• 487 people accessed community outreach programs and 431 people accessed Mirikai Residential Care AOD Program, exceeding annual targets.  
• 93% of clients experienced improvement from the service (quarterly result). 

• High client satisfaction rate of 86%, for the service for the year. 
• Since the easing of COVID restrictions, face-to-face delivery and virtual appointments are being offered to clients depending on preference and need. 
• Higher numbers of clients remaining in treatment. 

Service Provider

• Lives Lived Well 

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Quality Improvement 

We provide support to general practices, the cornerstone of primary care, in their provision of high-quality care for Gold Coast residents. The support provided ranges from working with general practice teams implementing data informed quality improvement (QI) activities to providing access to information and resources through a dedicated phone and email support line, newsletters and the Gold Coast Primary Health Network (GCPHN) website.  

Achievements 

• Procured Australian General Practice Accreditation Limited (AGPAL) to develop an online eLearning platform to build internal and external workforce capability to achieve high performing primary care on the Gold Coast, through upskilling general practice and GCPHN staff in core quality improvement training.  
• This eLearning Platform was utilised by 74 general practice staff and 14 GCPHN staff who used the training to develop skills as QI facilitators/coaches. 
• Fifteen general practice staff were recruited as QI champions, to lead practice teams to identify, implement, monitor and evaluate QI activities.  
• GCPHN staff facilitated two QI activities focussing on increasing cervical screening rates and improving immunisation rates in vulnerable population groups.  
• Ten practices that participated in the cervical screening QI activity and had a QI champion, had higher rates of cervical screening recorded after completion of the program, than those who did not (48.1% compared to 41.3%).   
• GCPHN staff support 170 Gold Coast general practices to meet the requirements of the Australian Government Department of Health and Aged Care Practice Incentive Program Quality Improvement initiative. They do this through the provision of quarterly data reports and providing an opportunity for general practice staff to review results and identify opportunities to implement QI activities.  

Cancer Screening 

We play a key role in raising awareness in the Gold Coast community about the importance of participation in the national bowel, breast and cervical cancer screening programs, and supporting quality improvement initiatives for general practices, to promote screening among their patients. 

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Achievements 

• Supported staff across 30 general practices to implement a team based cervical screening quality improvement activity aimed at improving the number of female patients with an up-to-date cervical screening.  
• On average, general practices participating in this activity increased their rate of cervical screening by 6% in the year after commencing the program.  
• An increase in recorded cervical cancer screening rates across the participating general practices means that by the end of 2021/22 year, an additional 2,177 women aged 25-74 residing on the Gold Coast have received cervical screening or had screening appropriately recorded. 
• At the conclusion of the program in June 2022, the rate of cervical screening amongst participating general practices reached 43.6%, compared to 37.6% before the commencement. In contrast, practices that did not participate in the program, saw little improvement in their data, and in fact saw a decline of 0.5% compared to the quarter prior to commencement. 
• To raise awareness about the importance of cancer screening to residents, and provide information, advice, and training opportunities to health professionals, we have published 42 articles promoting cervical, breast and bowel screening, in our publications and on social media. 

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Results for participation rate for the eligible population in the national cancer screening programs for the region and nationally.

Source: AIHW, National cancer screening programs participation data Bowel and breast cancer: 2019/2020 Cervical cancer: 2018/2020 

Immunisation 

We have continued to support general practices to keep immunisation levels high, to better protect local residents against disease and have played a key role in influenza immunisation and the COVID-19 vaccination program. 

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ACHIEVEMENTS 

• Immunisation support has focused on the COVID-19 vaccine program with development and communication of resources, training, quality improvement toolkits and webinars. 
• From April 2022, 30 practices have been participating in an influenza immunisation QI activity which concludes in October. The aim of the activity is to improve vaccination rates for patients aged 65 and over, or patients with diabetes or COPD.  
• As Shingles immunisation was identified as a priority for 71–79-year-olds, we collaborated with the Healthily Go Share program which provided a data solution to identify and recall eligible patients. Of seven general practices that participated, 232 patients were vaccinated (an average of 15% across the general practices).  
• Twelve general practice nurses were sponsored to complete the Endorsed Nurse Immuniser Program to lead a team-based immunisation quality improvement activity within their general practice.   
• More than 89 articles were published to local residents and health professionals to promote immunisation and to provide information and advice. 

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My Health for Life 

We have been part of the Queensland Government funded My health for life program since 2017. This program helps Queenslanders at risk of developing chronic conditions, including type 2 diabetes, heart disease and stroke, to live well and reduce their risk factors by making lifestyle changes such as healthy eating and increased physical activity.  

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Achievements

• In the last 12 months, 418 consumers have commenced the program and 2,009 risk assessments have been completed. 
• There has been a 56% increase in consumers completing the program. 
• The Primary Healthcare Improvement Team continues to raise awareness about the program among GPs and practice nurses, which is embedded into relevant continuous quality improvement activities and through PIP quality improvement activities. 
• Promotion of the program has included the publication of 43 articles published through social media, the GCPHN website and online newsletters, to promote the program to general practice staff, health professionals and the community. 
• Additional work has been underway to identify options to promote the program for hard-to reach groups including men, culturally and linguistically diverse communities and those living in rural and remote areas.

Health Promotion

Stakeholders

Building the Primary Care Workforce

Since 2005, we have been instrumental in helping shape the future of the primary health workforce. Partnering with Griffith, Bond and Southern Cross universities, we help train the next generation of GPs and practice nurses, by placing medical and nursing students in general practices across the Gold Coast, northern NSW and Brisbane. 

Achievements 

Medical Placements 

• 576 medical students completed 4,669 days of placement. 
• 239 GPs were involved in student supervision. 
• Satisfaction surveys showed that 95% of students felt there were sufficient opportunities to promote their learning and 80% of final year students strongly agreed/agreed that following their placement, they feel confident to work in General Practice.  

Nurse Placements 

• 189 nursing students completed 2,705 days of placement. 
• 83 practice nurses were involved in student supervision.  
• Satisfaction surveys showed that 94% of respondents strongly agreed/agreed there were sufficient clinical opportunities to support their learning and 79% strongly agreed/agreed that following their placement that they would now consider a career in general practice.  

Specialist Placements 

• We organised 36 non-compulsory specialist placements across three specialties (Dermatology, Ophthalmology, Musculoskeletal). 

Stakeholders

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Primary Care Engagement and Digital Health

Gold Coast Primary Health Network (GCPHN) has implemented a number of initiatives to engage with general practice staff and healthcare providers to promote quality improvement initiatives and digital technologies. This has included promotion and education about digital health tools such as Smart Referrals, HealthPathways,  My Health Record (MHR), telehealth, electronic prescribing and secure messaging.  

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Achievements

• The telephone and email Helpdesk, staffed by our Primary Healthcare Engagement staff, continued to provide invaluable support to Gold Coast general practice staff and other healthcare providers. 
• A number of internal processes have been streamlined to enable GCPHN to keep general practice details updated to facilitate prompt engagement across all program areas. 
• Gold Coast general practices (100%) and 99% of pharmacies have renewed their NASH PKI Certificate, so they can securely transact with My Health Record (MHR) and other digital health systems.  
• All eligible medical practices (100%) who refer to Sullivan and Nicolaides Pathology (including specialist practices) have been educated on enabling e-requesting to ensure pathology results are uploaded to MHR.  
• As of May 2022, approximately 48% of Gold Coast private specialist practices were registered for MHR which is more than double the current national average of 23%. 
• Two champion specialist practices were recruited to assist in the promotion and use of the MHR system and were part of the expert panel at the Digital Systems and My Health Record in Specialist Practices event. 

Stakeholders

Digital System and My Health Record in Specialist Practices Event 

The Gold Coast PHN hosted an event for specialist practices on 12 July 2022. The event attracted a range of specialists and practice managers and gave attendees an opportunity to hear from our own local specialists about the benefits and how they have been using My Health Record. 

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In response to the Royal Commission into Aged Care Quality and Safety, the Commonwealth Department of Health has developed and funded a more significant program of work that will see Primary Health Networks managing a number of new aged care activities.

We have been allocated new funding of over the next four years (from 2021/22), to use our existing expertise and relationships with local health service providers to commission a range of activities to keep people at home, delaying entry into aged care facilities and reducing avoidable hospitalisations for senior Australians.

The focus for this year has been in working collaboratively with our stakeholders in the planning, which has included undertaking needs assessments, service mapping and scoping of evidence-based models for implementation in the next financial year. A brief outline of the aims of each of the programs is outlined below.

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Support for Residential Aged Care Facilities (RACFs)

Support RACFs to increase availability and use of telehealth care for aged care residents

We will be assisting participating residential aged care facilities to have access to telehealth facilities, equipment and training for staff to enable their residents to have video consultations, when needed, with their primary health care professionals, specialists and other clinicians.

Enhanced after-hours support for residential aged care

This project aims to support participating residential aged care facilities to implement individualised after-hours management plans, in line with residents’ wishes and to be aware of after-hours health care options and referral pathways and utilise these when needed.

Aged Care and Dementia Clinical Referral Pathways

In May 2021, Gold Coast Health implemented an electronic platform, Gold Coast Community HealthPathways, where GPs can access clinical and service referral pathways for specific medical conditions or health needs. This project is a partnership between Gold Coast Health and Gold Coast Primary Health Network to develop and launch a wide range of specific aged care and dementia pathways.

Dementia Consumer Pathway

The aim of this initiative is to support people living with dementia to live well in the community for as long as possible, through easy access to information on dementia diagnosis and initial and ongoing services and supports to people living with dementia, their carers and families. This will help to support them to plan ahead to better navigate their dementia journey.

Care Finder Program

Supporting aged care service navigation

We are supporting the development of a new workforce called ‘care finders’ who will provide specialist and intensive assistance to help people to understand and access aged care services and connect with other relevant supports in the community. Navigating the aged care system is complex, and the target group for this program will be those who require more intensive support and include some of our most vulnerable people in the community. The care finders will ensure these people have access to the most appropriate aged care supports and services by working with them and building rapport and trust. Once services are commenced, the care finders will provide follow up to ensure needs are being met. The service will commence in January 2023.

Early Intervention to Support Healthy Ageing

Senior Australians are being supported to live in the community for as long as possible and minimise some avoidable risks of early entry into residential aged care. As part of the planning, we will explore services or supports to prevent, identify, and reduce chronic disease and health issues, avoid inappropriate hospital admissions and improve health outcomes for senior Australians.

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During 2021-2022, we supported activities for palliative care patients at home or living in residential aged care facilities (RACFs) and their staff, to improve their quality of care and their end-of-life experience. 

Stakeholders

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Specialist Palliative Care in Aged Care (SPACE)

Funded by the Commonwealth and state government with additional funding from Gold Coast Primary Health Network (GCPHN), the Gold Coast SPACE project provides RACFs with education, training and capacity building through the innovative use of ‘Palliative Care Needs Rounds’, which are triage meetings with RACF staff and clinicians, focusing on residents at risk of dying without as plan in place.  

Achievements 

Funding to extend this program has enabled additional staff allocation and expanded service delivery to more RACFs and residents.  

• Results for 2021-2022: 
  • 91% of Gold Coast RACFs are involved (exceeding the original target of approximately 50%) 
  • 809 referrals  
  • 273 proactive, pre-emptive Palliative Care Needs rounds completed 
  • 144 urgent reviews 
  • 68 family meetings  
  • 161 clinical telephone support calls   
  • 130 Gold Coast GPs involved 
  • 130 education sessions to nurses and care workers  
• Results of project since commencement (2019- 2022):  
  • On average 130 residents seen/month 
  • 31% reduction in RACF emergency department presentations  

Greater Choices for at Home Palliative Care

We received pilot funding to improve the coordination and integration of end-of-life care across primary, secondary, tertiary and community health services to support patients who wish to receive palliative care in their home environment. The program has now been funded until June 2025, with the focus on building the workforce capability of primary care workers in palliative care and bereavement support. 

Achievements

• The Advance Care Planning consumer health literacy guide Planning your future care today (booklet and online information) was published in July 2021 on the GCPHN Advance Care Planning webpage for consumers. To further support consumers and health care professionals to initiate conversations around End-of-Life care planning, GCPHN have 10,000 printed copies of the booklet, with 2,500 booklets disseminated within the community. 
• Promotion of the Advance Care Planning Continuous Quality Improvement (CQI) Toolkit and CQI Exemplar on the GCPHN website, has resulted in 80 downloads in 12 months, which will support the increasing conversations and uptake of Advance Care Planning. 
• Ten nurses working in Gold Coast region were approved and funded to participate in Program of Experience in the Palliative Approach (PEPA) palliative care training and clinical placements. 
• Ten general practitioners working in the Gold Coast region will be offered funded opportunities to complete PEPA training and clinical placements later in 2022. 
• Resources to support culturally safe palliative care for First Nations People were promoted during National Reconciliation Week. 

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The Gold Coast Primary Health (GCPHN) website, www.gcphn.org.au plays an important role in providing timely, accurate and evidence based information and resources to health professionals and the local community. The website has continued to build a strong domain reputation as a trusted source of information. 

 User numbers have been very high throughout the pandemic as general public and health professionals sought reliable information in frequently changing circumstances. Some of the information that has been curated for local health professionals includes COVID-19 management pathways, downloadable patient resources, latest updates and alerts and vaccination information. The COVID-19 pages were also one of the most viewed by community members with information about testing, vaccination and living with COVID. 

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Achievements

• Engagement with the website continues to grow, with 266,822 website users in 2021-2022, an increase from 156,820 the year before.  
• There have been on average, 43,159 page views per month. Total page views over the last 12 months was 517,916, an increase of 141,938 from the year prior. 
• Web traffic seeking non-COVID related resources is higher than previous years and continues to rise as GCPHN has built valued resources for GPs and consumers. 
• Page views supporting general practice went up by 91.4% compared to the previous financial year. 
• GCPHN social channels have seen an 11% increase in followers overall, 7.5% on Facebook, 2.4% on Twitter, 22.9% on Instagram and 23% on LinkedIn, over the past 12 months. We use these channels to proactively disseminate information to the community and local health professionals. 

Stakeholders

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We play an integral role in the development of the primary healthcare workforce with training, education and communication to ensure health professionals have access to the latest information to provide the highest level of patient care. 

Our training activities are aligned with quality improvement activities and are accredited.  

We have commissioned Australian General Practice Accreditation Limited (AGPAL) to develop an online eLearning platform to build internal and external workforce capability to achieve high performing primary care on the Gold Coast, through upskilling general practice and GCPHN staff in core quality improvement training. In the last 12 months:  

• Training consisted of five eLearning modules and six live webinars, which are all available on the platform as on-demand resources. 
• This eLearning Platform was utilised by 74 general practice staff and 14 GCPHN staff who used the training to develop skills as QI facilitators/coaches. 
• Fifteen general practice staff were recruited as QI champions, to lead practice teams to identify, implement, monitor and evaluate QI activities.  

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We often partner with industry leaders, to support online and face-to-face education and training events across a range of topics and areas with an emphasis on priority health needs and quality practice. In the last 12 months some topics have included:    

Achievements

• In the last 12 months we have held 56 education and training events attended by 1,169 people. This has included practice nurses and managers, GPs and registrars, allied health, specialists and administrative staff.  
• Feedback from internal and external event facilitators consistently indicates levels of high satisfaction with the level and type of training and education support from a content perspective as well as the events and communications support for the activities. 

Stakeholders

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Gold Coast Primary Health Network Financial Statements 2021-22

GCPHN Financial Statements for the year ending 30 June 2022