Aim: To effect on-the-ground change to communication, referral pathways, connectivity, discharge summaries etc. to provide a conduit for direct responsiveness to issues between HHS’ and general practice and provide continuous feedback to the PHN regarding needs and issues. 

The GPLOs will work within the PHN Clinical Excellence team and assist with the HealthPathways project as well as preparing GP workforce for HealthCare Homes, when appropriate.

Activity:

• General Practice Liaison Officers funded through the Darling Downs and West Moreton PHN and placed in the Darling Downs and West Moreton HHSs with a focus on linking hospitals  directly with General Practices across the region.
• Case Conferencing Officer funded via the Darling Downs and West Moreton PHN to manage integrated care and case conferencing between West Moreton and Darling Downs HHS and General Practitioners across the region. This Case Conferencing Officer would manage care planning between GPs, Palliative Care Specialists and patient/family/carers for people with end stage heart failure or non-malignant lung disease to improve and increase palliative care in the community and reduce Emergency Department presentations and hospitalisations.

This activity is based on a pilot study funded by Darling Downs and West Moreton PHN of case conferences between the patient’s GP and specialist staff to facilitate care planning for people with end stage heart failure or non-malignant lung disease in West Moreton.