How the puzzle fits together - what are the current and potential links between programs and between sectors
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Notes regarding pie chart and pieces of the puzzle map
Pie Chart
This chart represents the interfaces between the service domains or sectors of hospital, aged care, community care and general practice with the client at the centre of this chart.
The pie chart is a prompt to think about the interfaces and transitions between service sectors and the relational aspects between the sectors in terms of the interdependence, substitution and coordination of programs, services and sectors.
Transitions between sectors are a point at which clients have a greater risk of slipping through service gaps or receiving poorly coordinated care. It is therefore important to consider how we can best coordinate and collaborate between sectors to ensure the best possible patient care across all services.
Map of Selected Primary and Community Health Care Related Programs
This map represents primary and community health care related programs across continuum of care (Primary Prevention through to Continuing Care) by Service Domain (Hospital, Aged Care, Community, General Practice).
The map is not meant to be comprehensive, rather it provides examples to illustrate the spread, variety and nature of programs. In reality the service type and continuum of care categories may not be entirely discrete categories, for example the boundary between what is provided by NSW Health in the hospital and in the community is now being intentionally blurred.
The map is a way to encourage thinking about the myriad of programs available and how they relate to continuum of care and service types with the aim of improving the navigation and coordination of these programs at the local level.
Questions for consideration
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In terms of the interfaces between various service sectors (hospital, aged care, community, GP) what works well and what are the benefits for patients, providers and the health system when these interfaces work well?
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What are the problems and risks for patients, providers and the health system when these interfaces do not work well? What could work better in relation to these interfaces and what would be needed to make it work better?
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Should we design "bridging" services specifically to manage an interface (eg. care coordinators, case managers) or should we build this responsibility into the work of providers in one or a number of the major service domains (eg. outreach services from hospitals into the community, or in-reach services from the community to the hospital)?
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Which services/programs should be linked as a priority? Why and how should these links be made? How do we consider equity of access to these services and programs, some of which are population based and others which are client based.
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What observations can be made about the spread and distribution of services across primary prevention, secondary prevention, tertiary prevention and continuing care?
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What is the relative investment of resources across the continuum of primary through tertiary and continuing care (eg. is there enough attention being paid to primary prevention?)
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Thinking about integrated primary and community health, how can the sectors work together to ensure primary through tertiary and continuing care can be best provided to clients?
This web page is managed and authorised by Inter-Government & Funding Strategies of the NSW Department of Health. Last updated: 30 March, 2009
