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Standards for general practices (4th edition)

including Interpretive guide for Aboriginal and Torres Strait Islander health services

Standard 1.6 Coordination of care

Our practice engages with a range of relevant health and community services to improve patient care.

Criterion 1.6.1

Engaging with other services

Our practice engages with a range of health, community and disability services to plan and facilitate optimal patient care.

Indicators

► A. Our practice team can demonstrate how we plan and coordinate comprehensive care by our interaction with other services such as:

  • medical services including diagnostic services, hospitals and specialist consultant services
  • primary healthcare nurses
  • allied health services
  • pharmacists
  • disability and community services
  • health promotion and public health services and programs.

Services providing care outside normal opening hours

► B. Our service seeks feedback about the quality and responsiveness of our service from the practices whose patients we see.

Explanation

Key point

  • Engaging with other services is an important feature of high quality healthcare.

Engaging with other services for optimal patient care

Engaging other medical services (eg. diagnostic services; hospitals and consultants; allied health; social, disability and community services) can assist the practice to provide optimal care to patients whose health needs require integration with other services.

Coordination of care for individuals, families and communities is part of the accepted definition of a GP. Where relevant, practices are encouraged to coordinate patient care across the general practice setting with other health services including allied health and pharmacy as well as social, disability, indigenous health and community services. The practice needs to have readily accessible written or electronic information about local health, disability, community and mental health services and how to engage with them to plan and facilitate patient care.

It is important for practices to identify relevant services within the local area that can enhance patient care, to develop registers of such services and to build good working relationships with these service providers to facilitate good collaborative care. These registers will be particularly useful for new members of the practice team.

Practices need to be aware of different referral arrangements for public and private providers.

Services providing care outside normal opening hours

Services that provide care outside normal opening hours may, where clinically appropriate, coordinate referrals through the patient’s usual GP/general practice.

Standard 1.6 Coordination of care

Our practice engages with a range of relevant health and community services to improve patient care.

Criterion 1.6.1

Engaging with other services

Our practice engages with a range of health, community and disability services to plan and facilitate optimal patient care.

In a nutshell

Good working relationships with other service providers and networks will support the provision of comprehensive care to your patients. Your health service could have information registers easily accessible to your clinical team for easy and up-to-date referrals. These are a good resource to facilitate the planning and coordination of comprehensive healthcare in order to meet individual patients’ health needs.

Key team members

  • Health service manager
  • Office administration staff
  • Clinical staff

Key organisational functions

  • Register of health, community and disability service providers
  • Networking and collaboration with health, community and disability service providers
  • Referral protocols

Indicators and what they mean

Table 1.12 explains each of the indicators for this criterion. Refer to Criterion 1.6.1 Engaging with other services of the Standards for general practices for explanations of some of the concepts referred to in this criterion.

Table 1.12 Criterion 1.6.1 Engaging with other services
IndicatorWhat this means and handy hints
▶ A. Our practice team can demonstrate how we plan and coordinate comprehensive care by our interaction with other services such as:
  • medical services including diagnostic services, hospitals and specialist consultant services
  • primary healthcare nurses
  • allied health services
  • pharmacists
  • disability and community services
  • health promotion and public health services and programs.
Your health service provides easily accessible resources for clinical staff to plan and coordinate comprehensive care in collaboration with other services. This resource is typically a register of (usually locally) available services, such as those identified in this indicator. But because ACCHSs aim to provide holistic care to their patients, you may interact with a much wider range of services, including schools, employment and housing agencies, and social workers.

The register should be regularly updated with important contact details such as location, phone numbers and, where appropriate, the main contact person for different query types. Where appropriate, information about referral arrangements could also be included.

It is recommended that in rural and remote services, and where appropriate, the register also includes:
  • contact information of cultural liaison officers and/or cultural mentors
  • interpreters or interpreting-service phone numbers
  • other culturally appropriate information for clinical staff.
Information could be in either written or electronic form. It is also important to demonstrate that your clinical staff can access the information easily (that is, if stored electronically, they have access to the system).
Services providing care outside normal opening hours
▶ B. Our service seeks feedback about the quality and responsiveness of our service from the practices whose patients we see. If you offer a service after hours, it is inevitable you will see patients who do not usually present to your service but to another GP in another service. When this happens your service is expected to regularly seek feedback from these practices about the quality and responsiveness of your after-hours service to their patients.

Case study

Below is a description of the ways in which an Aboriginal community controlled health service can engage with other services to provide good healthcare for its patients and community. Not all of these good practices are required by the Standards, but they illustrate the many practical and creative things that ACCHSs can do to ensure they deliver services of high safety and quality to their community.

The health service is proactive in identifying external services within its region with whom it could work to enhance patient care and improve the health and wellbeing of the community. These services go beyond healthcare providers and extend to schools, housing and employment agencies, sports clubs and social workers. The health service tries to build good working relationships with all these other services.

The health service holds regular meetings with all the key external services it works with, so that issues and opportunities common to all can be discussed.

Many staff within the health service are responsible for maintaining contact with the external services, as appropriate to their role and responsibilities. Where appropriate – for example, if there are personnel changes or a new service or program developed by the external agency – the staff member will report that back to the health service, so that records can be updated.

Some of the external services with whom the health service has developed a strong relationship now partner with the health service on various activities. For example, they might undertake training together, share resources such as meeting rooms or jointly deliver a preventive health workshop to the community.

Key details of each external agency are recorded on an electronic and paper-based register of services, which the practice manager reviews and updates at the end of each quarter. The paper-based register includes clinical services as well as local organisations with which the service deals, and is located at the reception desk. The electronic register is incorporated into the clinical software program. Individual staff members add to the register when new services/organisations are used.

The Medicare Local list of practitioners, specialists and allied health providers is also kept at the reception desk for easy reference, along with the roster of on-call pharmacies. This allows staff to let patients know which pharmacy is available on weekends.

The remote clinic has the 24-hour contact details for the Royal Flying Doctor Service and standardised forms for transfer of patients out of the community.

Showing how you meet Criterion 1.6.1

Below are some of the ways in which an Aboriginal community controlled health service might choose to demonstrate how it meets the requirements of this criterion for accreditation against the Standards. Please use the following as examples only, because your service may choose other, better-suited, forms of evidence to show how it meets the criterion.

  • Keep an electronic or hard-copy register of service providers and organisations to which staff may refer patients.
  • Update the register regularly and document the date of update within the register.
  • Keep an easily accessible list of pharmacies including the roster of on-call pharmacies.
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