Western Sydney LHD
Western Sydney LHD and WentWest (Western Sydney Primary Health Network) are delivering a joint program, building on previous work in chronic disease management and integrated care from Connecting Care and HealthOne.
Targeted patients are being enrolled into a Patient-Centred Medical Home in general practice and empowered to understand and manage their chronic disease. Care coordination and care navigation are features of the program, with Care Facilitators located within community and primary care tasked to monitor and provide patients with referral to health coaching, self-management strategies, and specialist and other health care services.
Specialists and hospital acute clinicians will be focused on providing care to the most complex patients and support capacity building within the community transition and primary care teams, working across the ‘whole of district’ and in partnerships with WentWest and GPs.
The Western Sydney Integrated Care Programme, in partnership with WentWest, conducted a three part series of workshops over April and May 2015 to introduce GPs to the newly developed models of integrated care across General Practice and Acute, Specialty and Community based services.
Central Coast LHD
Central Coast has a ten year vision to transform the system of care so that care:
- Is designed and delivered to be person-centred
- Is a seamless and comprehensive continuum
- Results in an effective outcome that is desired by the person
- Is efficient.
System redesign through strategic purchasing and developing an IT platform to support integrated and patient-focused care are central components. The development of a 'commissioning for outcomes' framework has commenced, with an initial focus on analysing and understanding the patterns of health and social support service use for the Central Coast population.
Strong existing partnerships and a range of potential partners with other agencies include Family and Community Services (FACS), NSW Police and Education. There is a strong social component with three Proof of Concept Clinical models being driven, focused on the vulnerable aged, people with chronic and complex issues and vulnerable youth patient cohorts.
The Central Coast Integrated Care Program recently collaborated with the University of New South Wales to produce the Report on Predictive Models for Emergency Hospitalisations which identifies some important predictor variables to identify people who are at higher risk of hospitalisation in the next 12 months.
By strengthening community and primary services, as well as the capacity for people to self-manage, Central Coast LHD aims to reduce avoidable hospital admissions and representations and deliver care in the most appropriate setting for the patients’ needs.
To date, pilot projects have been established to test hospital avoidance, winter respiratory care management, hospital in the home, community geriatrics, centralised intake, 48 hour nurse follow-up, local responses to child protection, youth clinics and youth primary health pathways as part of the ‘Caring for the Coast’ Strategy.
Western NSW LHD
Western NSW LHD aims to transform existing services into an integrated system of care that is tailored to the needs of rural and remote communities and improves access to care and health outcomes, with particular focus on closing the Aboriginal health gap.
Western NSW LHD is driving an ambitious, system-wide program focused on review, change management and increasing capability across the system with primary care providers. The program is supporting the delivery of a high performing primary care system, through key enablers including enhanced connectivity across multidisciplinary teams, flexible workforce planning and shared care planning tailored to individual needs. As part of this, a 12 month pilot of the electronic shared care planning tool, cdmNet, has commenced in Western NSW.
‘Proof of Concept’ local demonstrator sites are delivering location and Aboriginal-specific models of integrated care which depend on strong partnerships with General Practice, NGOs, pharmacy, Aboriginal Medical Services and private providers amongst others. Care Navigators have been recruited at each of the five local demonstrator sites (Cobar, Cowra, Dubbo, Molong and Wellington) and have begun implementing the integrated models of care. Enrolment of patients at the all the sites has commenced with over 400 patients involved.
A strong governance structure, incorporating Medicare Locals the Primary Health Network in joint decision making with Aboriginal Medical Services, and the WNSW Integrated Care Clinical Leadership Committee has been established as part of the program. The Clinical Leadership Committee is providing clinical governance for the Strategy and driving identified initiatives to enable integrated models of care, for example Integrated Care Pathways and enhancing specialist support for primary care.