Community Health Plan

2006-2009

KINGSTON BAYSIDE PRIMARY CARE PARTNERSHIP

Contents

MESSAGE FROM THE CHAIR
ACKNOWLEDGEMENTS
BETTER HEALTH – STRONGER COMMUNITIES
KINGSTON BAYSIDE COMMUNITY HEALTH PLAN 2004-2006 - REVIEW
ORGANISATIONAL STRUCTURE
SERVICE COORDINATION
SERVICE COORDINATION WORKPLAN
CHRONIC DISEASE MANAGEMENT
MENTAL HEALTH
HEALTH PROMOTION
MENTAL HEALTH & SOCIAL CONNECTEDNESS
PHYSICAL ACTIVITY
FOOD & NUTRITION
COMMUNITY PARTICIPATION
INITIATIVES DEVELOPED WITH KBPCP AND NOW AGENCY RESPONSIBILITY

It is with pleasure that I introduce the latest Community Health Plan for the Kingston Bayside Primary Care Partnership.

The Plan incorporates the ongoing work that is being undertaken by our many member agencies and looks to maintain the outstanding level of achievement produced by the Partnership since its inception in 2000.

This document details our successful outcomes from the previous two year period and presents the next 3 year plan which has been the subject of a considerable amount of time and energy by the various KBPCP work committees. 

The level of commitment by agency members is evidenced by the sheer volume of work to be attempted – there is no reduction to our efforts or our expectations.

On behalf of the Committee of Management I thank all agencies and their staff and the project team for their ongoing support, commitment and individual contributions to the success of the KBPCP.

Robyn Trebilco
Former Chair

Challenges

The Ministers for Health and Aged Care have approved the continuation of the current PCP strategic directions, and that DHS will use PCPs to better integrate community based initiatives and programs to prevent and better manage chronic disease. The message from the Minister and the DHS reinforces the future of PCP –"Primary Care Partnerships remain a feature of the Victorian Health System."

There is general agreement that the future of partnerships requires necessary supports and the right incentives for those partnerships that are doing well.

Such programs like the chronic disease management programs provide a timely reminder to key partners that well progressed partnerships will be rewarded. KBPCP will be building on efforts to date and the challenge then is to ensure member agencies continue to benefit from their participation in the Partnership.

Kingston Bayside Primary Care Partnership Strategic Directions 2006-2009

The development of this Plan is the product of considerable effort and involvement from many individuals and organizations.

Kingston Bayside Primary Care Partnership Management Committee:                                               

And equally to the working group participants, our appreciation is extended:

Working Group Members
Service Coordination
Health Promotion
GP Reference Group
Middle South Primary Mental Health Advisory
District Planning Group
Community members who participated in workshops and consultations
Department of Human Services

The Project Team:
Terry Lazzarotto
Meredith Herold
Tony Vivian
Deborah Burke

Consultants:
Ro Saxon
Colleen Johnson
Primary Health Care in Action – Jen Missing & Dr Sue Rosenhain
HOW Projects – Lyn Wright & Kari Hawke

For copies or more information:
If you would like copies of information contained in this Plan, or further information about KB PCP,
 contact Terry Lazzarotto, Executive Officer (03) 8587 0317,
tlazzarotto@cbchs.org.au

Kingston Bayside Primary Care Partnerships Member Agencies:

The Community Health Plan (CHP) is an operational plan that establishes goals, objectives, service system change strategies, governance, monitoring and accountability and describes how the partners are working together to achieve the aims of the Primary Care Reform.
The Parties to our Memorandum of Understanding has been reviewed and signatories retain a commitment to the co-operative development of an integrated, consumer responsive primary care system that maintains and promotes the health and well being of individuals and the broader community.
The Parties to the Memorandum are committed to the following key principles for the next three years:

• Collaboration and co-operation
• Sharing of information
• Implementing identified and agreed strategies
• Joint planning
• Recognising the diversity of the service system and the skills and knowledge of participants and
• An inclusive and culturally sensitive process, which involves communication and consultation with agencies, consumers and the community.

The Primary Care Partnership project is now entering its seventh year and it is worth reminding ourselves of what has been achieved:

• A recognised framework for bringing members together to consider local issues and respond with a united voice on Primary Care Reform matters
• An ongoing commitment to progressing Primary Care Reform
• Improved communication between members
• Improved understanding of member agencies’ roles, capabilities and concerns
• Demonstrable progress in service coordination and integrated health promotion.

The Chairs of the thirty one PCPs across Victoria convened the State-wide Chairs and Managers Forum in 2002 and from that time have collectively worked to guide and promote the work of PCPs to the State Government.
The Chairs Forum is now a multi sector voice to the Government on many issues including important policy development.
In promoting the achievements of the Primary Care Partnerships, the Forum has been successful in:

• Maintaining open communication with DHS Primary Health Branch
• Securing funding for Primary Care Partnership specific initiatives
• Conducting a very successful state-wide conference, showcasing Primary Care Partnerships and shaping future partnership work
• Looking to the future, addressing training needs for Chairs and Managers.

With the completion of the 2004-06 CHP, the Partnership will continue to build on its achievements and lead the primary health and community service reform.

The activities described in 04/06 CHP that will continue to be built upon this year are:

Partnership

The Partnerships gained new members (25% increase) through its work in Service Coordination, Mental Health, Integrated Health Promotion and its facilitation role in drawing agencies together to investigate and develop proposals for funding opportunities.
KBPCP continues to work with the three other Southern Metropolitan Region’s PCPs in investigating regional partnership opportunities as well as collectively advocating on future directions for the program.

Mental Health

The KBPCP Mental Health Advisory Committee initiated projects around:
GP and Mental Health Services Communication
Central Bayside, Monash and Dandenong Divisions of General Practice, Southern Health Adult Mental Health Services and PCP member agencies are stakeholders in this project aimed at improving communication between GPs and Area Mental Health Services using SCTT and establishing Shared Care Agreements.

A major project examining improved responses to mental health issues by agencies has commenced.

Work on both projects continues in the new 06 - 09 Plan.

Service Coordination

Partnership members continue to embed service coordination into their agency systems.  The focus of much of our work over the last two years has been the uptake of Service Coordination Tools Templates and Protocol development, and the implementation of electronic client information recording and referral systems. 

All member agencies now have E-referral capability and the challenge is to maintain the momentum gained to this point.

Progressing ERef and GPs use of PCP Referral Systems

Central Bayside, Monash and Peninsula Divisions of General Practice are stakeholders in this Project to increase the capacity of Practices to participate in service coordination with PCP agencies.
This project will link with Southern Health GP Project promoting the use of ConnectingCare as a referral tool.

Southern Health OutPatients has lead the way in e-referrals involving GPs, with nine GPs using the system consistently and a monthly increase with new GPs coming on board. Projects involving Argus and ConnectingCare are continuing to develop.

Regional Strategic & Consultative Group / IM-IT Working Group

KBPCP is participating in the Regional Strategic & Consultative Group (RSCG). This group has encountered some of the first really difficult negotiating between the PCPs in this region, and it has been proven to have the capacity for all participants (PCPs / SMR Regional Office) to meet and negotiate satisfactory outcomes.
 
These two groups have now merged and will be working on new regional priorities over the next three years.

Service Planning

KBPCP service planning has a catchment approach and incorporates priorities and future directions from key stakeholders.

In effect, key stakeholder plans influence what KBPCP does, in particular, in Health Promotion Planning.

GP Reference group

In partnership with Central Bayside, Monash and South City Divisions of General Practice and Inner South East Partnership in Community Health, KBPCP provides funding support for the Regional General Practice PCP Reference Group.
The Reference Group has now become Regional Reference Group incorporating the Southern Metropolitan Region PCPs and continues to focus on improving the quality of communication between GPs and primary care providers, increasing participation in the electronic client information referral project and promoting the use of the Statewide Referral Form.

Health Promotion

The Partnership has a very energetic and committed Health Promotion focus to its work as detailed in this outline of the previous two years:

Kingston Bayside Primary Care Partnership has had as its priorities Mental Health and Wellbeing and Physical Activity since 2000. This has been seen as a strength for the Partnership.

• Funding received for Talking Realities for next 3 years

• Talking Realities is a peer education program aimed at training young parents in a program that is presented in secondary schools about the realities of parenting at a young age

• Health and Active Living Funding as well as Well for Life Funding (WFL)

• Assisted in developing the physical activity strategy for 2004-2006
• Again secured WFL funding
• The rollout of both Strength Training and Tai Chi into PAG (Planned Activity Groups) has had it challenges and the model for delivery of these activities is currently being adapted.

• With many of the program based initiatives now being led by these groups, this table shows the growth in both the Partnership and the direction of health promotion for the catchment:

Service Coordination

Service Coordination Committee commenced its 06/09 planning process in April 2006 and established six goals that were important to the Kingston Bayside member agencies.
The outcome of that process underlines KBPCP’s commitment to the successful implementation of the Service Coordination framework and its benefits to consumers.

 Goals

1. To support evidence based practice and the effective use of resources.
2. To ensure ongoing implementation of service coordination in accordance with DHS PCP requirements. This includes the desire for continual improvement and agency practice reflecting the principles, elements and features of the Service Coordination Framework.
3. To continue to work with GPs to implement service coordination, and in particular, electronic referral.
   
4. To continue to support the acute sector to implement service coordination.
5. To support the development and/or implementation of statewide service coordination initiatives.

The service coordination goals complement the Department of Human Services’ vision, which has remained constant.

DHS Overall Vision (unchanged)

• To support priority human services agencies which are new to Service Coordination implement the Better Access to Services (BATS) framework;
• To work with Divisions of General Practice to support general practices to improve the quality of referral and care planning and in particular, implement the Victorian Statewide Referral Form;
• To continue to support agencies that have successfully implemented the BATS operational framework for initial contact and INI and to support those agencies to implement BATS operational framework for assessment and care planning.

The workplan maps out the course of service coordination activities to be undertaken over the next 12 months.
A midyear review will examine the range of strategies required for 2007/08

Elements of Service Coordination

Goal 1: To support evidence based practice and the effective use of resources.

DHS – creation of Service Coordination audit tool (agency non identifiable snapshot summary) support for QiPPS / EquiP / QICSA models

Goal 2: To ensure ongoing implementation of service coordination in accordance with DHS PCP requirements. This includes the desire for continual improvement and agency practice reflecting the principles, elements and features of the Service Coordination Framework.

Goal 3: To continue to work with GPs to implement service coordination, and in particular, electronic referral.

Goal 4: To continue to support the acute sector to implement service coordination.

Goal 5: To support the development and/or implementation of statewide service coordination initiatives

Goal 6: To ensure that the PCP structure is designed to achieve key strategic priorities

PCPs have an important role to play in bringing services together to develop systems that support a coordinated approach to the planning and delivery of service to clients with chronic disease.

CBCHS has recently been funded as part of the Early Intervention into Chronic Disease Management Program (EIICDM) and is currently developing its model and implementation plan.
KBPCP’s role will be to work with CBCHS to include relevant member agencies in the delivery of its CDM model.

At this stage, KBPCP Service Coordination Committee and the Project Team will be considering the following activities and measures to be included in the 2006-2009 Community Health Plan.  It is anticipated that this work will be completed by December 2006. 

Focus for activity in 2006-2009

All PCPs

• Map the existing service system for self-management. Moderate and facilitate planning processes for self management with member organisations to respond to gaps identified in the mapping process
• Define roles and responsibilities of service providers, especially acute and CHSs in relation to the provision of self management interventions for people with chronic and complex needs and document this in local PPPS. In addition, describe in local PPPS, the process for determining the most suitable self management intervention for individual clients, including where and by whom the intervention is best delivered
• Improve integrated chronic disease management for those clients with chronic and complex conditions by reviewing and including specific requirements in local PPPS for the identification of clients requiring this intervention and cross disciplinary / multi organisation, (including GP) Care Planning
• Improve levels and the quality of care planning for clients that require it including GP involvement
• Continue to implement the BATS framework by progressing common practices, processes, protocols and systems for initial contact, initial needs identification, referral, assessment and care planning by member organisations, particularly as it relates to people with chronic disease and complex needs
• Strengthen approaches to address disadvantage and health equality in IHP, including barriers to participation such as chronic disease.

PCPs working with one or more CHSs funded under the EIiCD initiative

• Improve communication and participation of agencies, particularly GPs, in care planning
• Develop information management systems to support care plan implementation, monitoring and review
• Support the adoption of care pathways to ensure that clients get the right care in the right place, regardless of where they enter the service system
• Support delivery system design that means agencies provide proactive care rather than reactive care
• Develop and implement decision support tools and clinical information systems to support chronic disease management care implementation, monitoring and review
• Support related workforce development, including approaches to self management for CHSs and general practice
• Support communication and marketing strategies (developed in conjunction with the DGP) that promote the benefits and availability of local self management interventions to GPs
• Dissemination of transferable change management lessons
• Compliance with AIPC evaluation framework.

Measures 2006/07: Measuring Partnership Progress

All PCPs

• Satisfactory completion of the Integrated Chronic Disease element of the Community Health Plan, which complies with DHS frameworks, and addresses identified ICDM foci (3 yr plan with annual review and updates if required)
• Summary findings from self management mapping exercise
• Inclusion of a statement in local PPPS which identifies the specific roles and responsibilities of organisations such as acute and community health services in the provision of self-management interventions. In addition, include in local PPPS, a process for determining the most suitable self management intervention for clients, including where and by whom the intervention is best delivered
• Inclusion of content relating to integrated chronic disease management in PPPS, including cross disciplinary/multi organisation, (including GP) care planning
• % of member organisations that have implemented the integrated chronic disease management component of the PPPS including cross organisation/ multidisciplinary (including GP) care planning
• % of member organisations with clear criteria for identifying clients requiring care planning and a process to audit compliance with the criteria.

PCPs working with one or more CHSs funded under the EIiCD initiative

In addition to the requirements for all PCPs, those PCPs funded at a level, which is above the minimum funding under the Early Intervention in Chronic Disease initiative, should supply the following:

• % of member organisations that have implemented systems that support care plan implementation, monitoring and review
• % member organisations that have implemented systems that support care pathways implementation, monitoring and review
• % member organisations that have implemented changed communication systems with General Practice relating to integrated chronic disease management
• Number of presentations to practice nurses through continuing nurse education sessions and/or to GPs through continuing professional development sessions on available self management interventions.

As highlighted in the previous Kingston Bayside Community Health Plan, Mental Health remains a priority health issue for the KBPCP, and reiterates the rationale for its priority focus, namely:

• Mental health problems are a significant personal and social problem
• The costs of mental health problems are significant
• Interventions to promote mental health need to be at the community level and not just with the individual
• Mental health promotion is a key concern for Primary Care Agencies.

The Mental Health Advisory Committee (MHAC), which has both PCP members and non-PCP members and is convened under the KBPCP Management Committee and was established with four areas as a focus for its activities:

1. Partnerships and holistic care planning
2. Provider knowledge / literacy
3. Access for people with dual disability
4. Community access and participation.

The MHAC has initiated two major Mental Health Promotion projects entitled:

1. Improving the response to mental health issues, the objectives of which are to ensure a better understanding of the profile of particular population groups with mental health issues and that KBPCP member agencies better coordinate their mental health strategies within the Kingston Bayside catchment and


2. Improve the communication between service providers and GPs

Implementation process KBPCP 2006-2009 CHP

The process for developing the 2006-2009 CHP began in October 2005, after evaluating the 2005-2006 CHP and recognizing that some objectives were not measurable.

All member agencies and interested service providers from non-member agencies were invited to participate in an inclusive process to developing the 2006 – 2009 CHP.  Efforts were made to expand involvement in the planning process in response to issues identified as part of the KBPCP Health Promotion Committee undertaking the Partnership Analysis Tool.

The process for the development of the 2006-2009 CHP began with a brainstorming exercise where everyone was invited to present their current and future priority areas, which were then collated and enabled KBPCP to develop an overall picture of the future.

The Management Committee supported the recommendation to initiate a facilitation process to further develop the plan. This was embarked on, not just as a process for developing the plan, but also as a process of capacity building in both the partnership and workforce areas.

Representatives nominated and worked in priority areas of their choice, expertise and interest. The priorities chosen were a reflection on past work and an identification of emerging issues. Both Mental Health and Physical Activity remain priorities of KBPCP, whereas Food and Nutrition is an emerging issue. Community Participation is seen as an area that will need initial input and then the practice will be embedded into Health Promotion and all working groups.

The facilitated process continued over three sessions and the smaller working groups met independently to this and developed rationale, goals and objectives supported by the KBPCP Health Promotion Coordinator.

• The Health Promotion Committee then reviewed the draft IHP plan
• Management Committee endorsed the draft IHP plan and process
• the goals and objectives were developed and  the evaluation framework and plans were finalized
• Membership of each working group has been established
• Chairs to these working groups have been elected and implementation commenced

As a sign of the growing maturity of the Partnership, 45 individuals were involved in this process, representing a broad cross section of agencies including both primary care and non health related agencies, member and non member agencies. The Partnership is now capturing a range of workers from various agencies in both the planning and delivery of the CHP.

The strong representation from non-member agencies has also enhanced the Partnership. These agencies are seeing that the KB PCP:

• Is an effective partnership
• Is a supportive environment
• Is achieving set goals

Summary:
The development of the 2006 -2009 CHP has been more inclusive than before and has included a broader cross section of agencies and representatives. It has enabled growth in terms of participating members, the scope of the plan and its flexibility. This process has delivered and improved goals, objectives and strategies that are both achievable and measurable.

Vision Statement

The Kingston Bayside Primary Care Partnership will work collaboratively to empower communities of Kingston and Bayside to optimise their health. Embracing the Social Model of Health, the Partnership will deliver quality Health Promotion Initiatives.

Summary Statement of Primary Care Partnerships

The Kingston Bayside Primary Care Partnership members consider that the alliance is one of cooperation where integrated health promotion is a priority. There is a high level of trust between partners and the capacity to enhance the members for mutual benefit and a common purpose.

Priority Topics

Mental Health & Social Connectedness
Physical Activity
Food & Nutrition
Community Participation

Partnership Investments

The Department of Human Services has allocated $207,000.00 to the Kingston Bayside Primary Care Partnership to deliver Integrated Health Promotion activities for 2006 - 09. The Partnership members have demonstrated their response through the commitment of their agencies to the objectives outlined in the appendices templates.

It is important to note that this agency commitment can also be translated into a substantial financial indicator. This table represents the investment by KBPCP and its member agencies into Health Promotion over the life of the current work plan timelines and is not indicative of the commitment for the total 2006 – 2009 CHP.

Supporting Rationale

Definition: Mental Health is the embodiment of social, emotional and spiritual wellbeing. Mental Health provides individuals with the vitality necessary for active living, to achieve goals and to interact with one another in ways that are respectful and just.

Global Evidence:
There has been increasing recognition of the growing impact of mental health problems and disorders. It is predicted that by the year 2020 depression alone will be the second highest cause of disease burden worldwide. Addressing this burden has been identified as a pressing priority of the World Health Organization.

Psychological risks such as insecurity and lack of control over one’s work and home life can increase the chances of poor mental health with those who are most disadvantaged at greatest risk:

• Those living in poverty or unemployed
• Those who are ill, disabled, emotionally vulnerable
• Migrants, ethnic minority groups, refugees and their children
• Those who experience violence
• Children in their early years whose parents experience mental exhaustion and depression

• Those who are socially isolated.

National Evidence:
Poor mental health is recognised as a growing cause of morbidity in Australia.
Depression is a risk factor for cardiovascular disease, diabetes and cancer, significantly affecting people’s quality of life.

Young people – a sense of stability, positive school experiences, opportunities to take part in purposeful activity, social support and friendships, and control over their lives are recognised as important in promoting resilience in young people in care.  Outcomes as adults were better for those children that had a lasting and significant relationship with at least one parental figure or with one of the two families they had been dependent on.

State Evidence:
The VicHealth framework identifies three overarching social and economic determinants of mental health;

1. Social inclusion is about making sure that all children and adults are able to participate as valued, respected and contributing members of society. Mental health is a key outcome of social inclusion.
2. Addressing violence and discrimination.  Race, ethnicity, sexuality, disability and gender are factors that contribute to social exclusion.

Youth violence, bullying, child abuse and neglect, family violence, abuse of the elderly, sexual abuse and self harm are identified as violence. Partner violence is responsible for 9 percent of the total disease burden for women aged 15 – 45 years.

• Increasing access to economic resources.  People with lower levels of income security have significantly worse health outcomes.  Living with persistently low income contributes to heart disease, diabetes, and poor mental health.

Young people reporting poor social connectedness (that is, having no one to talk to, no one to trust, no one to depend on and no one who knows them well) are between 2 and 3 times more likely to experience depressive symptoms compared with peers who reported the availability of more confiding relationships. Evidence of significant and persistent correlation has been found between poor social networks and mortality from almost every cause of death.

Young People experiencing homelessness experience poorer health outcomes and are reluctant to access mainstream health services.

Families - Experiences in childhood lay the foundation for mental health later in life. Investing in programs that not only focus on children’s health but support and connect parents through all stages of children’s growth and development has resulted in significant benefits to the physical and emotional health of families.

Young parents often experience social, economic and educational disadvantage. Children’s access to environments that support healthy development are largely governed by the socio-economic circumstances of their parents. Promoting young parents mental health and social inclusion, in turn fosters their children’s opportunities for social participation and skill development.

Older People spans the age group from 65 years and over and/or who have an age related disability. There is strong evidence that higher rates of mental health problems in older people are associated with bereavement and/or isolation or lack of social networks. Socially isolated people die at two or three times the rate of people with a network of social relationships and sources of emotional support.

People from Culturally and Linguistically Diverse (CALD) backgrounds are more likely to experience discrimination and racism, which impacts on self esteem, feeling of belonging and personal safety. Equity in opportunities to belong or connect to a community is essential to the promotion of mental health.

Local Evidence:
Burden of Disease data (2001) reveals that depression is ranked in the top 5 conditions for both males and females in Kingston and Bayside.  Dementia is in the top 5 conditions for females in Bayside and Kingston, the top 5 for Bayside males and in the top 10 for Kingston males.  Suicide is ranked 11th for Kingston males and 12th for Bayside males.  Generalised anxiety disorder is in the top ten for both Kingston and Bayside women.

Ischaemic heart disease is the top ranked condition for both males and females in both Kingston and Bayside (Burden of Disease 2001).  According to the National Heart Foundation, depression, social isolation and lack of social support are significant risk factors for coronary heart disease that are independent of risk factors such as smoking, high cholesterol and hypertension and are of a similar magnitude.

City of Kingston identified mental health and social connectedness as a priority in the Municipal Public Health Plan 2006 – 2009. Parents who participated in the development of the City of Kingston Early Years Plan identified social isolation and poor transport as contributing factors to their mental health. 

A community that is inclusive and provides opportunities for everyone to participate in community life is a goal of the Bayside Municipal Public Health Plan 2004-2008.  Adolescents, older adults, low-income households and recent mothers are identified target groups for Bayside.

A City of Bayside consultation with community members and service providers identified a need for parent education sessions for parents with preschool children.

The Kingston Bayside Primary Care Partnership (KBPCP) Health Promotion Strategy ‘Depression and Emotional Wellbeing in Older Persons in the Kingston Bayside Area’ was undertaken by RDNS Institute of Community Health in 02-03.  The report found:

• Most elderly people with depression simply wanted to participate in more social activities and to have “someone to talk to”
• The main barriers to elderly people getting support for emotional problems from local services were ill health, disability and a lack of knowledge about where to find help
• Better coordination was needed between community health service providers in relation to the way clients with depression were assessed, managed and referred to other agencies
• Approximately 40 percent of service providers were unable to estimate the percentage of their elderly clients who were depressed
• Only one-third of service providers had been required to train in mental health issues to help them manage depression in elderly people.

KBPCP identified mental health as a priority issue in the 2004/2006 Community Health Plan. 

Central Bayside Community Health Services and Bentleigh Bayside Community Health Service have identified mental health as a priority issue in their 2006/2009 Integrated Organisational Health Promotion Plan.

Local agencies working with homeless or at risk (of homelessness) young people have identified this group as having particular barriers to developing positive relationships and being part of supportive networks.

Problem Definition

Goal: To strengthen family and community connections in the Kingston Bayside Communities.

Target Groups:           

• People aged 65 years and over and/or who have an age related disability
• Young people: pregnant and parenting young women, secondary school students, homeless or ‘at risk’.

Objectives:

• By June 2009, Kingston Bayside Primary Care Partnership will have increased awareness about the relationship between teenage parenting and social connectedness in young people attending secondary schools in the Kingston Bayside area.
• By March 2007 Kingston Bayside Primary Care Partnership will have identified two strategies to increase social connectedness of homeless and ‘at risk’ young people living in Kingston and Bayside.
• By June 2007 Kingston Bayside Primary Care Partnership will identify two strategies to address social isolation in older people living in the Kingston and Bayside area.

Solution Generation

For the 2006-2009 Community Health Plan, the planned health promotion interventions are as follows:
Objective 1:

• To deliver Talking Realities Young Parent program to at least 4 schools in Kingston Bayside in 2006
• To deliver Talking Realities Peer Education and training program in 2007
• To continue to provide ongoing support and training to peer educators as required

Objective 2:

• To identify two strategies to increase social connectedness of homeless and ‘at risk’ young people by March 2007.

Objective 3:

• To identify two strategies to address social isolation in older people living in the Kingston Bayside area

Evaluation and Dissemination Planning

Evaluation Planning Summary Grid – Mental Health & Social Connectedness

Support and Resources

The key stakeholders are:

Objective 1 (Talking Realities Working Group):

Central Bayside Community Health Services
Bentleigh Bayside Community Health Service
Bayside City Council
Kingston City Council
Women’s Health in the South East
School Focused Youth Services
School representative
Southern Health/Alfred CAMHS

Objective 2 (Social Connectedness – homeless and at risk young people):

Bentleigh Bayside Community Health Service
Bayside City Council
Kingston City Council
Women’s Health in the South East
Southern Direction
Taskforce Community Agency JPET
Victoria Police
Centrelink
Young Women’s Outreach Program
Family Life
Fusion
Reach Out Southern Mental Health

Objective 3 (Social Connectedness – older adults):

Central Bayside Community Health Services
Bentleigh Bayside Community Health Service
Bayside City Council
Kingston City Council
Southern Health
Royal District Nursing Service
BaptCare
Sandybeach Community Centre
Reach Out Southern Mental Health
Middle South Primary Mental Health Team

Supporting Rationale

Definition:
Physical activity is all movements in everyday life, including work, recreation, exercise, and sporting activities.  (World Health Organisation, 1997)

Global Evidence:
Physical inactivity is one of the leading causes of major non-communicable diseases including cardiovascular disease, type 2 diabetes, some cancers and falls in the elderly. An integrated approach to addressing the causes of decreasing levels of physical activity will contribute to reducing the future burden of non-communicable diseases.

National Evidence:
Physical inactivity is recognised as the second most important risk factor that contributes to the burden of disease, morbidity and mortality in Australia. Fifty four percent of the adult population are not sufficiently active to achieve health benefits (7.27million).

State Evidence:
Physical inactivity is responsible for 4.1 percent of the total burden of disease and 68 percent of this burden is due to the increased risk of cardiovascular disease in inactive people.
Population groups at most risk:

• Women with dependant children
• People aged 40-50 years
• Those with lower levels of education
• Those with poorer health
• People who do not speak English
• People with low socio-economic status

Local Evidence:
Significant numbers of Bayside residents are not achieving sufficient physical activity levels to achieve health benefits.  In Bayside, the most frequent cause of injuries to older adults is a fall.

Kingston Bayside Primary Care Partnership (KBPCP) identified physical activity as a priority issue in the 2004/2006 Community Health Plan. 

Central Bayside Community Health Services (CBCHS) and Bentleigh Bayside Community Health Service have identified physical activity as a priority issue in their 2006/2009 Integrated Organisational Health Promotion Plan.

CBCHS Active Mums/Active Kids project identified of those surveyed only 24 percent of mothers with young reached the national guidelines for physical activity.

Problem Definition

Goal:                To improve participation in physical activity in the Kingston and Bayside communities.
Target Group: 

• Planned Activity Group (PAG) clients/participants
• People with low participation rates in physical activity within Kingston and Bayside communities.

Objectives:

• By June 2007 people attending PAGs participating in the ‘Well for Life’ project in Kingston Bayside area, will have increased their participation in physical activity.
• By June 2007, the KBPCP will have identified at least one group that has limited access to physical activity opportunities in the Kingston Bayside area.

Solution Generation

For the 2006-2009 Community Health Plan, the planned health promotion interventions are as follows:
Objective 1:

• To train staff and/or volunteers to provide strength training and tai chi
• To establish 4 new strength training groups in the Kingston Bayside area
• To establish 2 new tai chi groups in the Kingston Bayside area
• To increase the capacity of PAG workforce to assist in the promotion of physical activity

Objective 2:

• Collect information from KBPCP member agencies on identified needs.

Evaluation Planning Summary Grid - Physical Activity

Support and Resources

The key stakeholders are:

Bentleigh Bayside Community Health Service
Central Bayside Community Health Services
Bayside City Council
Kingston City Council
Southern Health
Leighmoor

Supporting Rationale

Definition:
“Healthy eating is more than just eating nutritious foods. It also encompasses the inherent cultural, economic and social factors of buying and preparing food, and sharing it with others.”

Food security is regarded as the state in which all persons obtain nutritionally adequate, culturally acceptable, safe foods regularly through non-emergency resources. Food security broadens the traditional concept of hunger, embracing a systematic view of the causes of hunger and poor nutrition within a community while identifying the changes necessary to prevent their occurrence.

Global Evidence:
Adults – Unhealthy diets and physical inactivity are among the leading causes of major non-communicable diseases including cardiovascular disease, type 2 diabetes and some cancers. An integrated approach to the causes of unhealthy diet and decreasing levels of physical activity will contribute to reducing the future burden of non-communicable diseases.

Babies – Maternal health and nutrition before and during pregnancy are important contributing factors in the prevention of non-communicable diseases, as is early infant nutrition.

National Evidence:
Nutrition is fundamental to health and to the prevention of disease and disability. Proper and adequate nutrition is closely related to optimal growth, good education outcomes and health throughout life, and contributes to the economic and social wellbeing of society. The prevention of nutrition-related diseases includes strategies to manage both over-nutrition and under-nutrition.

Under-nutrition is related to the nutritional density of the diet and remains a significant issue.
Vulnerable groups:

• Older adults,
• People with chronic disability and/or illness,
• Some Aboriginal and Torres Strait Islander communities,
• Socio-economically disadvantaged groups, including homeless people
• Those who suffer from substance abuse and/or alcoholism.

State Evidence:
Adults – Almost 20 percent of burden of disease attributable to cardiovascular disease and such health problems as diabetes are linked to poor eating. The disease burden associated with a high body mass is 8.0 percent of the overall burden. Ischaemic Heart Disease (IHD) is by far the largest cause of years of life lost in both men and women.

The majority of Victorians eat too few fruits and vegetables. Eating enough fruits and vegetables prevents mostly cancer and, to a lesser extent, IHD and stroke. Inadequate fruit and vegetable consumption accounts for 3.3 percent of the total disease burden.

Parents and children – 15 percent of 4-5 year olds are overweight and 6 percent are obese. Most parents of overweight children said they were not worried about their children’s weight. 16 percent of children consume no fresh fruit or vegetables and 28 percent have high fat foods at least 3 times a day.

Food security – In the adult population (people 16 years and over) food insecurity was higher in those persons on low income, with the highest percentage recorded in the 16-24 year age group on low incomes.

Vichealth provides the following information to support the development of the KBPCP food and nutrition priority issue:
Individuals and groups vulnerable to food insecurity include:

• Low income families (and single parents with young dependent children)
• People who are unemployed or have limited formal education
• People with a disability, including mental illnesses
• People from non-English speaking backgrounds (refugee and asylum seekers)
• Frail elderly people (particularly those who are socially isolated and have low incomes)
• People affected by alcohol and/or substance abuse
• Homeless people
• People from Aboriginal and Torres Strait Islander backgrounds

What influences peoples’ access to food?

• Economic – having adequate income or resources to buy food or having affordable food outlets in the neighbourhood
• Physical ability – ability to walk, drive and carry purchases home
• Physical infrastructure – availability of public transport or safe walkable routes, and geographical isolation
• Living conditions – stable address, adequate food storage and cooking facilities
• Cultural and social – whether there are shops with socially and culturally appropriate food

Local Evidence:
A school lunch box survey in a Bayside primary school found high fat and high sugar snacks amongst the highest recorded items in school lunches.

Parents and children – There is a predicted increase in the burden of disease associated with diabetes for both the Bayside and Kingston communities (2011 and 2016).

In two separate consultations with school communities and men 40 years and older, nutrition and healthy eating were identified as important issues for the Kingston community.

The Kingston School Nutrition project needs analysis identified two concerning issues:

1. Large percentage of children do not have breakfast, and
2. Snacks and lunches are often unhealthy with little or no nutritional value.

Kingston Council has identified the percentage of mothers breastfeeding dropping as more mothers are discharged earlier from hospital. Current rates show 40 percent of mothers are breastfeeding for 6 months. The National Health and Medical Research Council Dietary guidelines suggest 80 percent is achievable.

Both Central Bayside and Bentleigh Bayside Community Health Services have identified food and nutrition as priority areas in the 2004/2006 Organisational Integrated Health Promotion Plan.

Problem Definition

Goal:                To improve healthy eating in the Kingston and Bayside communities.
Target Group:  Kingston and Bayside communities (specific population groups to be identified in the planning process once partnership developed)
Objectives:

• By June 2007, Kingston/Bayside PCP will have agreed to work on a number of contributing factors that impact on food choices for people living in Kingston and Bayside.
• By December 2007, Kingston/Bayside PCP will have identified evidenced based strategies to promote healthy food choices for specific population groups.
• By December 2008, Kingston/Bayside PCP will have implemented at least 3 strategies identified in 2007.
• By December 2008, Kingston/Bayside PCP will have reviewed the food and nutrition plan and identified the objectives and strategies for 2009.

Solution Generation

For the 2006-2009 Community Health Plan, the planned health promotion interventions are as follows:
Objective 1:

• Establish collaborative partnerships between local agencies, government, non government and private sector organisations
• Identify contributing factors that influence food choices in specific population groups within the Kingston/Bayside community.

Objective 2:

• Identify best practice programs across a range of settings and population groups
• Develop a coordinated approach to promoting healthy food choices to specific population groups
• Develop a plan to involve community members in the planning, implementation and evaluation of the food and nutrition strategy.

Objective 3:

• Implement three best practice interventions to address food security

Objective 4:

• Evaluate current interventions
• Produce review document including evaluation and recommendations of the 2006/2008 food and nutrition initiative
• Develop further interventions for 2008/2009 in consultation with community members.

Support and Resources

The key stakeholders are:

Bentleigh Bayside Community Health Service
Central Bayside Community Health Services
Bayside City Council
Kingston City Council

Supporting Rationale

Definition:
Participation occurs when consumers, carer’s and community members are meaningfully involved in decision making about health policy and planning, care and treatment and the well-being of themselves and the community. It is about having your say, thinking about why you believe in your views and listening to the views and ideas of others. In working together, decisions may include a range of perspectives.
Department of Human Services, (2005) Doing it with us not for us, Melbourne

Global Evidence:
Community involvement in health (CIH), or participation, has been promoted by World Health Organisation (WHO) for many decades. The 1976 Alma Ata declaration made participation a central feature of primary health care.  The Harare declaration of 1987 outlined CIH as a process of direct public involvement in health systems, not only strengthening people's organization and skills, but also reorienting political and health systems to support such participation.

State Evidence:
Community members have shown improved health outcomes when they are involved in the decision making process and are provided with quality information on which to make decisions.

Community participation can lead to more accessible and effective health services and can facilitate increased participation by those community groups who are traditionally marginalised by mainstream health services.

“Partnerships between community members and health care workers provide opportunities for all to identify and address local health and wellbeing issues. This can result in empowering communities and reinforcing a sense of ownership and improved social connectedness”.

Local Evidence:
Kingston Bayside Primary Care Partnership acknowledges the importance of community participation in the draft document, ‘Consumer, Carer and Community Participation Strategy’ and in the development of the ‘Consumers and Carer charter which state, “That success in delivering the objectives of the Primary Care Partnership and in improving the health of our community relies to a great degree on the involvement of our consumers, carers and community.”

Bayside City Council states, “Community engagement enhances local democratic processes by encouraging communities to be informed and participate in the decision-making processes that guide the development of the services they receive.” 

Cental Bayside Community Health Services identified increasing community participation as a key strategy in the 2004/2006 integrated health promotion plan.

Problem Definition

Goal:                Community members are meaningfully involved in decision making and in the planning and delivery of health promotion activities.
Target Group:  KBPCP member agencies
Objectives:

• By October 2007 Kingston Bayside Primary Care Partnership will have a clear framework to support embedding community participation in health promotion activities.
• By March 2008 Kingston Bayside Primary Care Partnership will have reflected on the implementation and revised the Community Participation framework.

Solution Generation

For the 2006-2009 Community Health Plan, the planned health promotion interventions are as follows:
Objective 1:

• Identify and collate information and data relating to best practice in Community Participation
• Communicate finding of research to stakeholders
• Provide education and training to stakeholders
• Develop policies and procedures for embedding Community Participation in integrated health promotion for the Kingston Bayside Primary Care Partnership

Objective 2:

• Develop an evaluation plan to measure the impact of the Community Participation framework
• Revise Community Participation framework based on the findings of the evaluation.

Evaluation Planning Summary Grid – Community Participation

Support and Resources

The key stakeholders are:

Central Bayside Community Health Services
Bentleigh Bayside Community Health Services
Kingston City Council
Bayside City Council
Royal District Nursing Service
Reach Out Southern Mental Health
Middle South Primary Mental Health Team
Southern Health
Hanover
Sandringham Hospital
Central Bayside General Practice Association
Department of Human Services
Fronditha
Southern Mental Health Association
Victoria Police