Show Me The Plan
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.
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.
- Literature review
- Staff focus group questions
- Thematic analysis - staff focus groups
- Multidisciplinary communication tool
- Multidisciplinary communication tool [poster]
- Project Start: 24 July 2015
- Project end: 2 December 2015
- Implementation - the initiative is ready for implementation or is currently being implemented, piloted or tested.
- 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.
- 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.
- 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;
A/Operations Manager, Primary & Women’s Health (Clinical)
Justice Health & Forensic Mental Health Network
Phone: 02 9700 3241
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