The Darling Downs and West Moreton PHN region has communities and individuals experiencing significant mental health concerns, making it a significant focus for our PHN.

Our region has the highest percentage (nationally) of clients self-reporting current anxiety and 4th highest self-reporting current depression.

 There is elevated male mortality from suicide with 41% higher rate in the Darling Downs and West Moreton PHN region than the national rate. It is particularly high among men in Lockyer Valley, Scenic Rim, Somerset (47.8 ASR/100,000), and Western Downs.

 There is a demonstrated longer length of stay for mental health hospitalisations and our PHN ranks in the top 8 PHNs (of 31) for Intentional self-harm hospitalisations and bed days.

Our Focus:

Our stepped care model is currently being implemented and is aimed at improving service alignment and access for people experiencing mental health issues across a spectrum of concerns.

 We are working to:

• improve access to mental health services across the spectrum,
• facilitate improvements in service alignment,
• reduce the unmeasured burden of disease of mild and moderate areas,
• reduce self-harm rates,
• reduce self-harm hospitalisations,
• support suicide prevention and management

We have invested in a regional Suicide Prevention Plan which will be used to inform next steps and will be published in late 2018.

Key consultations and evidence indicate that recovery from substance misuse and addiction is affected by the availability, accessibility and affordability of preventative and treatment services.

Queensland Network of Alcohol and other Drug Agencies (QNADA) NGO AOD Services Report for the Darling Downs and West Moreton PHN illustrates that there are limited service and treatment options, such as brief intervention and counselling in the Darling Downs and West Moreton PHN region.

Our Focus:

We are working with service providers and the community to create an appropriately resourced system integrated with other health and community services.

Our focus is on creating client centred alcohol & other drug services in areas of highest need, therefore:

• improving the long-term outcomes for the individual,
• reducing hospital admissions, and
• improving social outcomes for the community.

Many Aboriginal and Torres Strait Islander people in our region have poorer health outcomes than non-Aboriginal and Torres Strait Islander people making culturally safe, person, family and community-centred care critical to our regional priorities.

Although many Aboriginal and Torres Strait Islander people have a good standard of living, too many experience unacceptable levels of disadvantage in living standards, life expectancy, education, health and employment.

 In Queensland, the life expectancy gap is currently estimated at 10.4 years for males and 8.9 years for females. During 2002-2006 Aboriginal and Torres Strait Islander children under five died at around three times the rate of non-Indigenous children (305.2 compared with 102.4 deaths per 100,000).

 The National Aboriginal and Torres Strait Islander Health Plan 2013-2023 outlines the strategies to be employed to make health systems accessible, culturally safe and appropriate, effective and responsive for all Aboriginal and Torres Strait Islander people.

Our Focus:

Our commitment is to continue to build strong relationships to empower Aboriginal and Torres Strait Islander Health Services, Organisations and Communities develop strategies to:

• Assist in service linkages that promote the attainment of Closing the Gap health outcomes.
• Improve access to primary health services for Aboriginal and Torres Strait Islander people.
• Improve the capacity of primary healthcare providers to deliver culturally competent and culturally safe care.
• Improve the patient journey along the continuum of care.  
• To improve understanding and develop solutions for the management of chronic conditions and health challenges associated with disability, maternal, child and youth mental and physical health, violence and substance misuse.
• Support workforce development in identifying opportunities incorporating increased cultural competence of health care workers and health care training for Aboriginal and Torres Strait Islander people.
• Investigate avenues to assist improving access to primary healthcare services and health outcomes for Aboriginal and Torres Strait Islander people through preventative screening, health assessments and immunisations. 

To forecast health workforce needs we must first understand the current workforce capacity including the models of care offered.

Our health workforce encompasses all individuals delivering heath care services to members of the community. Analysis of workforce gaps, retention and well-being across our region, requires thoughtful mapping against integrated models of care designed to meet community demand.

Our Focus:

We recognise that our workforce is our pillar and we continue to work closely with Health Workforce Queensland to assess needs and develop holistic strategies to support health professionals across our region. 

We are collaboratively working toward common goals and are committed to activities that support:

• improving access and continuity of access to essential primary health care,
• building health workforce capability, and
• growing the sustainability of the health workforce.

The medical community has been embracing technology more than ever, yet many primary healthcare providers are struggling with utilising this technology in the most effective way.

The aim of digital health technology is to improve information sharing between health consumers and service providers. These technologies are underpinned by national specifications, standards, services and infrastructure and are expected to deliver beneficial outcomes for all Australians in the long term.

 The Darling Downs and West Moreton PHN Clinical Excellence and Practice Support Teams have been working to support primary care providers to embrace a range of digital health technology initiatives to enhance the delivery of integrated, patient-centred care, and support patients to better manage their own healthcare journey. Within a medical practice, the right technology and systems can:

• allow physicians to access complete medical histories for their patients, supporting the ability to make quick decisions, thus improving patient outcomes,
• improve quality and workflow efficiency,
• improve profitability and sustainability.

Our Focus:

Our PHN Practice Support Team are working with healthcare service providers and Practice Managers across the region to implement clinical and administrative systems to support the digital health reforms and utilise specific digital technologies aimed at improving patient care and service integration. This includes training and support in data cleansing, Individual Health Identifier matching and transition to using My Health Record systems.

The Digital Health systems supported by our PHN include:

• Healthcare Identifiers Service – a national system for uniquely identifying healthcare providers.
• My Health Record – a secure online personal health summary that patients manage and are able to share with health professionals.
• Secure messaging – where information is transmitted between points of care securely.
• GP Access to the Queensland Health Viewer – a tool that allows general practitioners to view patient records associated with care delivered in Queensland hospitals.
• Electronic medication management
• Telehealth – supporting improved access to specialised care via technology.
• e-Referrals – participating in an electronic referral system.
• Access to the Australian Immunisation Register.

We recognise that elderly patients are best cared for via appropriate primary care and community management and empowered to stay in their own homes for as long as possible.

Nationally, Australia has an increasing aging population with an increasing number of elderly people with complex needs requiring residential care.

Our Focus:

Our commitment is to continue to build strong relationships to empower service providers and Communities develop strategies to:

• Reduce admissions to hospital and Residential Aged Care Facilities for older people and those with chronic disease, allowing people to maintain independence and reside in their own homes for longer.
• Plan for increased workforce and integration, to support projected need.
• Reduce social admissions for hospitals and Residential Aged Care Facilities.
• Ensure vital sharing of information at admission and discharge points to acute care facilities.
• Improve integration and coordination between regional services, Commonwealth and State programs in the Aged Care and Disability sectors.
• Access education, with a view to supporting decision making around future health care for patients.
• Ensure end of life planning is patient-centred with accountable clinicians working in primary care, hospitals and nursing homes. This will create options that enable patient wishes to accurately guide clinical management.   

Potentially preventable hospitalisations rates in the region are high in comparison to other PHN regions, with chronic and vaccine preventable conditions being the most common.

Chronic disease prevalence rates in the region are significantly higher than the state averages, and the health behaviours of the population commonly below the state averages, with weight, diet, physical inactivity and smoking being key contributors.

Premature mortality rates for all disease groups are significantly above the state premature mortality rates. The Darling Downs and West Moreton PHN ranked first in Australia for the greatest number of people per 100, who have one or more health risk factors such as smoking, high risk alcohol usage, poor diet and no or low exercise in the previous week.

The Darling Downs and West Moreton region is home to more than 10,000 people from migrant and refugee backgrounds of diverse cultures, signalling a need to ensure support to facilitate a smoother transition to the Australian healthcare system.

Our Focus:

To improve the health outcomes of people living in our region and reduce potentially preventable hospitalisations, the Darling Downs and West Moreton PHN is working with health professionals across the region to identify evidence-based programs that target our key priority population health issues.

Population Health strategies supported by our PHN include:

• Advanced care coordination – supporting clients with high and complex chronic disease needs to maximise health literacy and access to wrap-around services in a timely manner in an appropriate environment.
• Targeted self-management programs – empowering clients to effectively self-manage their chronic conditions and reduce deterioration, exacerbation or complication of their conditions which may require an acute response.
• Health promotion – supporting programs in shifting behaviours to better manage risk factors associated with chronic conditions and to reduce the likelihood of converting these risk factors to a chronic condition e.g. increase physical activity and healthy eating choices.
• Direct clinical interventions – commissioning providers to support high and complex chronic disease clients whose needs exceed those offered through Enhanced Primary Care, complementing existing service delivery through EPC referrals for chronic disease.
• Refugee support – working closely with refugee support services to improve partnerships and pathways for health assessments and screening, immunisation catch-ups, and referrals to health care providers including chronic disease services.
• Translation and interpreter services – continue the provision of translation and interpreter services for allied health and pharmacies not eligible for government subsidy.
• After hours primary healthcare – improving access to primary health care for people whose health condition cannot wait for treatment until regular services are available in the in-hours timeframe.
• Immunisation support – working collaboratively with the DDHHS and WMHHS to increase childhood immunisation rates by providing clinically appropriate support and resources to general practices on the National Immunisation Program.
• Supporting vulnerable groups – focus on developing solutions for refugee health, people experiencing homelessness and domestic violence, and integration and service access for people with disability.