September 2022 edition 

Integrated Care (IC) involves the provision of seamless, effective, and efficient care that reflects the whole of a person’s health needs: 
  • from prevention through to end of life 
  • across both physical and psychosocial health 
  • in partnership with the individual, carers, and family members.  
IC provides a value based approach to care in the community by: 
  • improving population health outcomes with targeted health interventions. 
  • improving people’s experiences through active participation to improve health literacy and self-management. 
  • improving providers’ experiences through shared care partnerships. 
  • impacting the system, encouraging regular primary care support, and staying well in the community for longer. 

Highlighting two integrated care initiatives: 

Integrated Care Emergency Department to Community 

The Integrated Care Emergency Department to Community (IC- EDC) 12-week initiative supports patients who present to emergency departments frequently. These patients usually have a high rate of co-morbidities and a range of complex health and social needs. They require an integrated, coordinated and supportive approach focusing on whole-of-person care to address their unique needs. 

Key to the success of this initiative is the ability of the team to build partnerships, expand professional networks between providers and engage in multidisciplinary case management and case conferencing. This enables the team to collectively understand each other’s roles in providing a web of care for a patient with highly complex health and social needs. 

Referral Pathways 

In March 2020, NSW Ambulance implemented a Residential Aged Care Facility secondary triage service to maintain the safety of some of our most vulnerable. It provided access to senior clinicians via virtual care, whilst supporting NSW Health's pandemic response.  

An evaluation of this service recommended expansion to the broader community, supporting care in the community and reducing non-essential presentations to emergency departments. 

This led to the implementation of the NSW Ambulance COVID-19 Virtual Clinical Care Centre in September 2021, successfully providing in-house secondary triage for COVID patients using virtual care. It involved employing a multidisciplinary team of professionals dedicated to secondary triage and referral.  

The Referral Pathways initiative aims to identify Triple Zero patients suitable for referral to a local health district community outreach service, providing more appropriate care closer to home, when clinically safe to do so.  

Supporting the development of more consistent referral pathways across local health district established services supports equity and access for all communities across NSW.  

Our aim is to always provide the right care, in the right place, at the right time, from the right clinician. 
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New patient journey:  

  1. Primary Triage to Dispatch to Emergency Ambulance Response  
  2. Primary Triage to Secondary Triage to Care Pathways (Extended Care Paramedics, LHD Services, GPs, Telehealth, community and social support services, and other transport options).  
  3. Primary Triage to Secondary Triage to Emergency Ambulance Response after clinical assessment indicated emergency ambulance care required  

Current as at: Wednesday 21 September 2022
Contact page owner: Strategic Reform and Planning