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Show Me The Plan

Justice Health and Forensic Mental Health Network
Project Added:
12 February 2016
Last updated:
22 April 2021

Show Me The Plan


Justice Health and Forensic Mental Health Network (JH&FMHN) developed a streamlined chronic disease process that addressed the barriers to completing a multidisciplinary care plan (MCP), by engaging frontline clinicians.

Show me the plan poster


To improve the screening and management of patients with chronic disease conditions, by increasing the volume of MCPs completed.


  • Improves the chronic disease screening process.
  • Increases the number of patients with a completed MCP .
  • Reduces waiting times for chronic disease screening.
  • Improves multidisciplinary communication within JH&FMHN .
  • Improves quality of care and service delivery.


In 2013, the NSW Coroner recommended a review of the chronic disease assessment and screening process, to reduce the time patients need to wait for a chronic care assessment. The need for timely identification of patient with a chronic disease and cohesive treatment management have been identified as key factors in reducing morbidly, mortality and unplanned admission to tertiary care in NSW . To address the recommendations of the NSW Coroner, a new and streamlined chronic disease process was required.


  • Stakeholder consultation was undertaken with frontline clinicians, including nursing staff and Aboriginal health workers.
  • Stakeholder feedback was gathered on the usability and functionality of the existing MCP , as well as barriers that clinicians felt prevented the completion of an MCP .
  • A new MCP was developed, in line with stakeholder feedback.
  • A review of chronic disease management processes was undertaken.
  • The new chronic disease screening process was trialled in rural and metropolitan JH&FMHN sites.

Project resources

Key dates

  • Project Start: 24 July 2015
  • Project end: 2 December 2015

Project status

  • Implementation - the initiative is ready for implementation or is currently being implemented, piloted or tested.

Implementation sites

  • Metropolitan Reception and Remand Centre, Silverwater Correctional Complex

  • Cessnock Correctional Centre


  • Primary and Women’s Health, JH&FMHN
  • Operations and Nursing, JH&FMHN
  • Information Management, JH&FMHN


  • The initial review of the chronic disease screening process and MCP found that only 6.7% of screened patients had a completed MCP .
  • Following implementation of the new chronic disease screening process, waiting times for chronic disease screening reduced from 82 to 37 days.
  • The new MCP is currently being approved for implementation, with results to be collected 3-6 months post-implementation (approximately mid-2016).
  • Additional evaluation will involve qualitative surveys and focus groups with clinicians, to gain their feedback on the new process.

Lessons Learnt

  • There is value in stakeholder involvement at every stage of the project.
  • The benefit of the MCP for clinicians is more relevant as a communication tool within the custodial setting.

Further Reading

  • Anaraki S, Plugge E, Hill A. Delivering primary care in prison: the need to improve health information. Informatics in Primary Care 2003; 11(4): 191-194.
  • Australian Government Department of Health. Chronic Disease Management (formerly Enhanced Primary Care or EPC) – GP services; 2014 [cited 2015 August 7].
  • Australian Institute of Health and Welfare (AIHW). The health of Australia’s prisoners 2012. Cat. no. PHE 170. Canberra: AIHW; 2013.
  • Bauer AM, Thielke SM, Katon W et al. Aligning health information technologies with effective service delivery models to improve chronic disease care. Preventive Medicine 2014; 66: 167-172.
  • Burt J, Roland M, Paddison C et al. Prevalence and benefits of care plans and care planning for people with long-term conditions in England. Journal of Health Services Research and Policy 2012; 17(1): 64-71.
  • Chronic Disease Management Office. Chronic Disease Management Program.  Sydney; 2015.
  • Møller L, Stöver H, Jürgens R et al. Health in prisons: A WHO guide to the essentials in prison health Health in prisons project. Denmark: World Health Organisation; 2007: 21-31.
  • Indig D, Topp L, Ross B et al. 2009 NSW Inmate Health Survey: Key findings report. Sydney: Justice Health; 2010.
  • Lloyd M. A practical guide to care planning in health and social care. United Kingdom: McGraw-Hill Education; 2010.
  • Mind Tools. Planning Stakeholder Communication; 2006. Available from:
  • Mitchell GK, Tieman JJ, Shelby-James TM. Multidisciplinary care planning and teamwork in primary care. Medical Journal of Australia 2008; 188(8): 61.
  • North East Primary Care Partnership. Readiness Checklist For Interagency Care Planning. West Heidelberg North East Primary Care Partnership; 2011.
  • The Australian Council on Healthcare Standards (ACHS). The National Safety and Quality Health Service Standards;


Hellal Hussein
A/Operations Manager, Primary & Women’s Health (Clinical)
Justice Health & Forensic Mental Health Network
Phone: 02 9700 3241

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