Successful proposals announced

Part of the $180 million NSW Government investment in new, innovative models of integrated care was allocated to a Planning and Innovation Fund to support discrete and innovative integrated care initiatives run by Local Health Districts (LHDs) and Specialty Health Networks with their partner organisations.

The Fund was tendered in 2014, with seventeen initiatives funded from across all LHDs and Specialty Health Networks. The initiatives cross a wide range of themes, patient groups, geographical areas and partnership models

More information is available on the assessment process and Frequently Asked Questions (FAQs).

The following initiatives were selected for funding until the end of 2016/17:

The Wollondilly Health Alliance

Led by South Western Sydney LHD

The Wollondilly Health Alliance  was formed to identify and address health care access issues in Wollondilly. The Wollondilly Health Alliance is a partnership between Wollondilly Shire Council, South Western Sydney Primary Health Network and South Western Sydney Local Health District.

The aim of the Wollondilly Health Alliance is to proactively address the ongoing health issues facing the Wollondilly community, and work towards creating a better serviced and healthier Wollondilly community.

The top health priorities the WHA is focusing on include future planning for health services aligned to predicted population increase, better sharing of patient health information between different health providers, improving access as well as community awareness of local health services, and attract and retain health professionals to the region such as General Practitioners, medical specialists and pathology and X-ray services.

There is also a strong focus on preventative health with a website  promoting healthy lifestyles and information on how to access local services. 

Custody to Community Integrated Care Program

Led by Justice Health and Forensic Mental Health Network

The Custody to Community Integrated Care Program aims to identify people most at risk, such as those with long term health conditions, mental illness, drug and alcohol misuse and cognitive impairment, and reintegrate them back into community based healthcare upon release from custody.

Support and brokerage for at-risk people to attend health and welfare services will be provided by an Integrated Care Worker, who will also provide assistance by arranging identification, housing support, education, employment, food, clothing and transporting patients as required to any appointments.

The Program aims to reduce numbers of newly released individuals presenting to acute community based health services for medication and unscheduled appointments, thus reducing the impact of this vulnerable population on the acute care sector and better integrating them back to community and primary care.

Far West in Focus

Led by Far West LHD

The Far West in Focus Program will deliver, design and implement an integrated model of care that meets the needs of Broken Hill residents, health professionals and provider organisations.

An eHealth strategy will be developed to improve quality and accessibility of electronic medical records, and data-driven approach used to inform people at-risk of health issues and identify the highest health priorities. One or more health priorities will be selected to trial a coordinated, integrated, GP-led, multidisciplinary model of care based on the notion of a medical home, with care navigators employed to coordinate care for enrolled individuals and deliver targeted health coaching.

The initiative will be expanded to include all at-risk populations in Broken Hill over subsequent years.

Healthy Homes and Neighbourhoods Integrated Care Initiative

Led by Sydney LHD

Sydney LHD aims to establish a cross-agency care coordination network to move vulnerable families with children from exclusion to inclusion; from dependency to independence. Vulnerable families will be identified when adults or children come in contact with health, education or community service providers. Care coordinators will work with partners, over multiple years, to ensure the family's health, parenting and education needs are met, they are connected to their local community, and services and supports are in place for the future.

All the needs of families are in scope for the intervention, including housing, employment, income support and legal advice. Geographical areas are being targeted in Redfern, Waterloo, Canterbury and Riverwood.

Evidence-based integrated care methods will be used to provide care, including family case conferencing and ‘wrap around’ care delivery. Support will also be provided to general practice in each of the targeted geographical areas to care for families that are often seen to be ‘too difficult’.

The Hunter Alliance - Care in the Last Year of Life

Led by Hunter New England LHD

Hunter New England LHD and partner organisations – including the Hunter New England and Central Coast Primary Health Network, Calvary, Hunter Medical Research Institute and NSW Ambulance - have formed a The Hunter Alliance aimed at improving the health of Hunter and New England communities.

The Alliance is delivering a regionally-based, integrated alliance of care for people in their last year of life. A community focused ‘Let’s Start Talking campaign provides information for people and their families to have difficult conversations about their wishes before and after dying.

The initiative also provides education and training for health professionals to develop the skills required for effective communication with people as they approach the end of their life.

The initiative has also co-designed the shared clinical tool, Netcare, with consumers to support the patient to have a better experience during their last year of life by encouraging conversation between themselves, carers, family and relevant clinicians earlier in order to be more proactive about important decisions, for example preferred place of death. The information in Netcare will be accessible for all clinicians involved in the patient’s care, and include relevant Ambulance protocols and out-of-hours General Practice advice as required.

The Moree Integrated Health Care Service

Led by Hunter New England LHD

A reform of health services in Moree will address the underlying social factors which impact on the capacity of individuals, families and the community to achieve good health outcomes. Interventions will be aimed to improve health behaviours and will connect public and private primary, community and hospital services in a way that builds on available health care resources and introduces pockets of innovation.

In the first phase of the initiative, the focus is on a new service that allows local Aboriginal women to access comprehensive antenatal care closer to home and receive referrals to specialist perinatal services. More information on the initiative is available in the Hunter New England LHD Health Matters Newsletter.

The next phase of the program will target people with renal failure so they are able to access dialysis and other care and support within the home.

Integrated Care Program for Whole of System Management of Chronic and Complex Conditions

Led by Northern NSW LHD

Founded on the patient-centred health care home (PCHCH) model, the Northern NSW Integrated Care Program will see transformative change in the way general practice, Aboriginal Medical Services, local Ambulance services, and acute and community services systematically deliver patient-centred wrap around care for selected patients with chronic disease and complex needs. Targeted patients will be supported by brokerage funding to purchase the most appropriate care coordination in a range of settings to deliver the right care at the right place.

Shared patient records, better use of technology and enhanced communications are a key feature of the program with the use of HealthPathways to provide evidence-based, clinical pathways to guide and support GPs to deliver consistent care. The Program is also supporting systemic changes for integrated care in Northern NSW including clinical redesign, and workforce planning and development.

Integrated and Intensive Care Management Across Sector Collaboration (IICMASC): For Patients with Chronic and Complex Care Needs

Led by Nepean Blue Mountains LHD

This Program is targeting individuals aged less than 70, who have multiple Emergency Department presentations to Nepean Hospital with chronic and complex care needs. The Program provides integrated and intensive cross-sector care management tailored to individual needs. By employing a robust cross-sector governance framework, it addresses system change and provides access to brokerage funds to fast-track purchase, integration and service delivery.

Determining triggers for high-level hospital utilisation will inform the Predictive Trigger Modelling tool, aiding earlier patient identification across settings and improving hospital avoidance. The Program builds on the successful Virtual Aged Care Service at Nepean Hospital.

KIDS GPS Integrated Care Service

Led by Sydney Children’s Hospitals Network

Kids Guided Personalised Services (GPS) provides personalised, coordinated and integrated guidance for children and their families through the current maze of health services. The child’s record, ‘My (Health) Memory’, will be in the family’s hands, always up to date and accessible through a mobile application.

The initiative aims to integrate care for a child with chronic health conditions by:

  • Forming a ‘circle of coordination’ around each child, for example including the family or carer, the community clinician, and the SCHN clinician responsible for the child’s care coordination;
  • Using eHealth technologies to develop an active and always current management plan that is available to the family and to treating clinicians;
  • Closing communication gaps between providers and patients using these technologies and forging new relationships between providers and patients and families; and
  • Educating and supporting the patient, family, carers and clinicians to achieve the best health outcome and wellbeing for the child.

Living Well, Living Longer: Working together for better health in people living with severe mental illness

Led by Sydney LHD

The Living Well, Living Longer initiative brings together primary care, mental health and specialist services to improve the physical health care provided to people living with severe mental illness. The initiative addresses the complex health needs of people living with mental illness who are known to have a lower life expectancy, but less likelihood of being screened and treated for physical health problems than the general population.

The Peer Workers work with the people with mental illness to link them a preferred General Practitioner to provide necessary health screening such as cardio-metabolic and other related screening, identify their health goals, and provide support for healthy lifestyle activities including health literacy, smoking cessation, dietary advice and exercise. The program is supported across Sydney LHD in the areas of cardiology and endocrinology, oral health, education and mental health. Strong consumer and carer engagement is key to the successful delivery of the program.

Multilevel Integrated Care Model Targeting Common Chronic Diseases in Sutherland Shire

Led by South Eastern Sydney LHD

The Program has established a new model of multi-level integrated care. It addresses two high impact diseases that the NSW population faces in increasing numbers - skin cancer and chronic wounds - within the Sutherland Shire. The new clinical model is person-centred and focused on delivery of timely assessment and treatment.

The Integrated Specialist Healthcare  service provides education and training to primary care to improve integration between GP services, Specialist services and the hospital network. The service spans across both private and public locations.

Musculoskeletal Initiative in Primary Care

Led by Northern Sydney LHD

In partnership with the Sydney North Health Network, Northern Sydney LHD aims to build capacity in primary care to deliver musculoskeletal models of care with corresponding hospital based services. Three models of care will be delivered as part of the program: Osteoporosis Re-fracture Prevention; Spinal (Back and Neck) Pain Pathway; and Osteoarthritis Chronic Care Program.

The program aims to provide patients with a better understanding of their condition and treatment options, improve their quality of life, better engage with care providers, and better comply with health care plans.

General practice will also have a better understanding of care providers appropriate for musculoskeletal conditions, and increasingly use chronic care tools and related MBS items better, including use of practice nurses for care plans and health coaching for the conditions the initiative is addressing. 

Nambucca Valley Integrated Care Initiative

Led by Mid North Coast LHD

The Nambucca Valley Integrated Care (NVIC) Initiative will deliver a collaborative between Mid North Coast LHD and community care providers within the Nambucca Valley, centred on the person and their needs, with a ‘no wrong door’ approach to break down traditional service barriers and silos.

A major focus will be changing the culture of service providers and the community in how services are communicated, accessed, provided and evaluated. This will include strategies to change the demonstrated pattern of sometimes inappropriate and expensive Emergency Department use to appropriate primary health care in the community, both in- and out-of-hours.

The initiative will target the entire Nambucca Valley population, with a risk stratified approach to guide the level of intervention and integration required. Key domains of aged care, mental health/drug and alcohol, chronic disease management, and family and child services have been identified to integrate care for those with more complex needs. The Aboriginal population will be a priority focus across all domains to close the gap on Aboriginal disadvantage.

Geriatrician in the Practice - Geriatrics Integrated GP/Specialist appointments

Led by Illawarra Shoalhaven LHD

The Geriatrician in the Practice initiative will address the high prevalence of dementia in the Shoalhaven region by improving knowledge and management of dementia in primary care.

The initiative involves a geriatrician and aged care nurse team accompanying the General Practitioner (GP) in their rooms and providing a joint, integrated appointment with the GP and specialist so it is easily accessible for people, in an environment they are familiar with and comfortable in. A joint management plan will also be developed in consultation with the geriatrician, GP and the person and their carer/s, with further care and follow-up transferred to the GP as appropriate.

The initiative is also providing education sessions to both GPs and practice nurses to improve the skills base for the management of issues that arise in dementia.

Psychogeriatric SOS (Services on Screen)

Led by St Vincent's Health Network

Psychogeriatric SOS will provide truly integrated care by using technology to bring multidisciplinary expertise to rural and remote health clinicians, from a range of backgrounds and in a variety of settings, who need assistance managing older people with mental health problems, mental illness and dementia.

Web-conferencing technology will be used to provide individually tailored clinical guidance, education, case review and multidisciplinary case-conferencing in order to:

  • facilitate multidisciplinary integrated care between the St Vincent’s Hospital Psychogeriatric Team and rural and remote clinicians in primary care, hospital and community services;
  • up-skill and empower rural and remote clinicians to locally manage mental health problems in their older people;
  • build capacity for rural and remote clinicians; and
  • develop a sustainable and cost-effective psychogeriatric eHealth outreach service model.

Stepping up the partnerships: assisting people through the lifespan and across communities

Led by Southern NSW LHD

The Southern NSW LHD Innovation and Integration project aims to develop partnerships with health care providers outside the LHD to develop innovative and integrated health care in the district for clients at risk of hospital admission.

The first priority is to develop and implement a rapid response model of care that will be able to respond to people who require urgent intervention in order to stay healthier at home.  The pilot population will be aged chronic and complex clients firstly in the Eurobodalla region. This model will then be transferred to vulnerable families and other groups of patients across the entire LHD.

The project will also see the development and application of a shared information platform enabling improved integration of health providers and case management of clients who would benefit from an integrated approach to health care.

The CHESS Initiative: Chronic/Complex Healthcare: Engaged with all Stakeholders and Services

Led by Murrumbidgee LHD

A Collaboration Network has been established by Murrumbidgee LHD in partnership with Murrumbidgee Primary Health Network, NSW Ambulance, Family and Community Services (FACS), BaptistCare and General Practitioners.

The Chronic/Complex Healthcare: Engaged with all Stakeholders and Services (CHESS) integrated care model places the General Practitioner at the core of care coordination for people with chronic and complex diseases to deliver both clinical and social support services to support people to stay at home and avoid hospitalisation or exacerbation of their disease.

Alternatives to acute hospital care will be provided to targeted patients, with GPs overseeing a coordinated multidisciplinary team and delivering clinical and social services tailored to suit the health needs of each individual.

Assessment and Selection Process

For more information on the assessment and selection process, please see the   Guidance Document for the Application and Selection Process for Local Health Districts and their partners and the Frequently Asked Questions (FAQs) compiled during the Planning and Innovation Fund application process.

A recording of the Industry Briefing held by the NSW Ministry of Health on 8 August 2014 is also available.

For further information on the successful proposals or assessment and selection process, email

Page Updated: Wednesday 18 November 2015
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