​​September 2022 edition 

The Integrated Care (IC) Emergency Department to Community (EDC) initiative is key to driving value based healthcare in NSW. Social determinants of health, risk factors and multi-morbid complexity across all chronic conditions impacts on documented health inequalities in WNSW.

Improving outcomes for vulnerable and at-risk populations and people with complex health and social needs who frequently present to our EDs is a key priority for our Integrated Care Planned Care for Better Health program and the IC EDC initiative.

The IC Care Coordinators aim to provide a better experience of care through a coordinated intervention that recognises the value of shared care across key partners and delivers effective and efficient person-centred care.


Case study 

A 57-year-old male was referred to the IC team after a grievance of his experience during a recent admission. Although the client had NDIS support in place there was limited communication post discharge with the primary care provider. The complaint investigation highlighted a lack of follow-up care after discharge and a local capability gap regarding the NDIS Pathway. 

The client had a recent history of several potentially preventable presentations to ED. A case conference was organized with the NDIS team, who requested IC input with client enrolment into the EDC initiative to assist with care coordination and navigating his care. 

The IC EDC coordinator arranged an initial meeting to talk with the client about the program, seeking his consent to complete a holistic person-centred assessment, with care plan development in partnership with his service providers. 

The client has a significant chronic and complex health history, physical disability, PTSD, and a recent episode of COVID-19. The health and wellbeing assessment resulted in a complex mix of physiological, psychosocial, spiritual, and mental health concerns. 

The clients aims or goals were the driving force for planning care and there was a discussion about possible future options. This involved multiple case conferences with the care team (multiple agencies and clinical disciplines) with the aim of ensuring the teams were aware of their role and the opportunity to gain expert input. This also gave the client the ability to add information about how he was feeling, what was working and what was not. This helped the team to re-align plans and goals to ensure client’s needs were being met. Given his health conditions, he was unable to leave the group home, so the team met in person and via video link to his room. 

The value of enrolling this client into EDC was multifaceted. Of great importance for the client was his ability to “have a voice in his health care needs”. While this may be an expectation, this gentleman was from a vulnerable population and had multiple admissions where he felt he had not been listened to. The role of case conferences was also important so the team could meet and have current updates about how the planning was progressing. 

Caring for clients in the community with chronic and complex health concerns necessitates a teams’ approach; this was another great advantage of the program for the client. Opportunities also existed to talk to care staff at the group home about aspects of the client’s care that would have positive health outcomes. Delivery of health coaching and improving health literacy benefits the client, and their professional carers.

Referrals to appropriate services were achieved with follow up care provided when required. Providing this information back to the client, GP and service providers were also an essential role for the EDC team. 

Valuable learning/outcomes 

  • Meaningful connections, facilitate partnerships and collaboration 
  • Addressing clients concerns needs are effective, he was able to be very involved in his care planning 
  • IC EDC team had a non-judgmental holistic approach, utilising opportunities to provide staff education when required 
  • Education to acute care staff on the REACH Program, to escalate care for inpatients that need additional support
  • Increased involvement from a multidisciplinary team to collectively work towards goal realization for the client 
  • Continuous interventions to meet goals, recent referral to CPAC to reduce hospital presentations and keep client in the home environment where he wished to stay 
  • Team approach that was collaborative and supportive, in challenging circumstances, for a client with social isolation and complex health concerns 
  • Senior management support was available when needed and opportunities to be innovative were encouraged 
  • Ability to use care models that are supported with an evidenced based, person centered, holistic framework 
  • Effective collaboration with the Primary Care team, supportive with referrals and advice 
  • Opportunities to provide feedback to services through complaint process 
  • Staff flexibility in adapting to changing circumstances and applying a person-centered approach to care.
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Value based health care anticipated outcomes are:

  • Improve health outcomes for the population
    • Empowers patients
    • Improve health literacy
  • Improve experience for patients, families, and cares
    • Patients actively participate in their care
    • Improved patient activation: ability to manage and escalate care when required
  • Improve experience for service providers and clinicians
    • Improve understanding of patient needs
    • Improved provider experience
  • Effectiveness and cost efficiency
    • Reduction in ED presentations
    • Reduction in unplanned hospital admissions
    • Reduction in total length of stay
    • Delivering proactive community based care
Current as at: Thursday 22 September 2022
Contact page owner: Strategic Reform and Planning